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California Coordinated Care Initiative: What Self-Advocates and Families Need to Know
By Amber Cutler & Michelle Rojas Soto February 12, 2015
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About Michelle Rojas Soto Moderator USC UCEDD Director of Community Education, Information Dissemination and Technical Assistance [email protected] www.uscucedd.org
The USC University Center of Excellence in Developmental Disabilities at Children’s Hospital Los Angeles (USC UCEDD) is one of 67 centers around the country. Our mission is to provide leadership in strengthening family-centered, culturally-competent services and systems for the benefit of individuals with, or at risk for, developmental, behavioral and/or special health care needs and their families in partnership with those who utilize the services.
About Amber Cutler Presenter Staff Attorney National Senior Citizens Law Center [email protected] http://www.nsclc.org
The National Senior Citizens Law Center is a non-profit organization whose principal mission is to protect the rights of low-income older adults. Through advocacy, litigation and the education and counseling of local advocates, we seek to ensure the health and economic security of those with limited income and resources, and access to the courts for all.
Glossary • Coordinated Care Initiative (CCI)
– Cal MediConnect
• Dual Eligible (Dual)
• Duals-Special Needs Plan (D-SNP)
• Fee-for-Service (FFS)
• Long Term Services and Supports (LTSS) – In-Home Supportive Services (IHSS), Community Based Adult
Services (CBAS), Multipurpose Senior Services Program (MSSP), Nursing Facility
• Medi-Cal Managed Care
• Program of All-Inclusive Care for the Elderly (PACE)
• Seniors and Persons with Disabilities (SPDs)
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CCI = three big changes
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CCI Change Description
Mandatory Medi-Cal Managed Care
Duals and previously excluded SPDs must enroll in Medi-Cal Managed Care
LTSS Integration LTSS added to Medi-Cal Managed Care plan benefit package
Medicare Integration (Cal MediConnect)
For duals, integration of Medicare and Medi-Cal benefits into one managed care plan.
The current Medi-Cal, LTSS, and Medicare delivery systems are different
Medi-Cal (medical services)
Medi-Cal (LTSS services)
Medicare
Managed care
Managed care
FFS FFS FFS
(default)
OR OR
*Behavioral Health
Current System
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CCI moves services into managed care
Medi-Cal (medical services)
Medi-Cal (LTSS services)
Medicare
Managed Care
New System
*Behavioral Health
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Managed Care: Plans paid to provide covered services via network providers
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Senior/Person with Disability
Provider
DHCS & Medicare
Provider Provider
$$
Health Plan DHCS &
Medicare
$$
Medi-Cal and Medicare
(Dual Eligibles)
Medi-Cal only (SPDs)
Medicare Only
Impacted Not
Impacted
CCI impacts duals & seniors and persons with disabilities with Medi-Cal
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Different groups of DUALS and SPDs are affected differently
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Medi-Cal Only (SPDs)
• Nursing Facility
Residents • Share of Cost
Medical Exemption Request (MER) Available
Duals Not CMC Eligible
• Regional Center
Clients • ESRD Diagnosis • In Waivers STILL HAVE TO CHOOSE
A MEDI-CAL plan
Duals Who Won’t Get
CMC Notices
•In certain Medicare plans •In Kaiser STILL HAVE TO CHOOSE
A MEDI-CAL plan
Exceptions: Duals and SPDs who reside in an ICF/DD, Veteran’s Home, or who have Other Health Coverage do not have to join a plan.
Total Impact: 1,125,000
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County Duals Subject to Passive Enrollment in Cal MediConnect
Medi-Cal MC Only
Alameda 32,533 48,000
Los Angeles 288,399 (200,000 cap) 317,000
Orange* 65,537 51,000
Riverside 40,040 46,000
San Bernardino 41, 930 54,000
San Diego 55,798 64,000
San Mateo 12 371 14,000
Santa Clara 37, 739 38,000
Totals 574, 347 ( 485,948 with cap) 632,000
Regional Center Clients Still Have to Choose a Medi-Cal Plan
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Regional Center Client
Medi-Cal
Passive Enrollment
www.NSCLC.org 15
Enroll
Dual
Choose a Medi-Cal Plan
Do Nothing Enrolled into
Medi-Cal Plan
What is the Medi-Cal Plan Responsible For if You’re a Dual
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• The Medi-Cal plan is responsible for benefits Medicare does not pay for: • Long-Term Services and Supports – In-Home Supportive Services ,
MSSP, CBAS, and Nursing Facility Care • Medi-Cal transportation services • Durable Medical Equipment • Certain Prescription Drugs • Medi-Cal Supplies
• The Medi-Cal Plan Pays the Medicare Provider the 20% Co-Insurance
• The Medicare provider DOES NOT have to be contracted with the Medi-Cal plan to bill the plan for the 20% co-insurance
Los Angeles Medi-Cal Plans
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• LA Care
– Plan Partners
• Anthem Blue Cross
• Care 1st
• Kaiser
• Health Net
– Plan Partner
• Molina
CCI will be implemented in 7 counties
Alameda Los Angeles
Orange Riverside
San Bernardino San Diego San Mateo Santa Clara
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Timeline – Los Angeles County
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• Most Duals who only have to choose a Medi-Cal plan do so by birth month (August 2014 Start Date)
• Duals in Medicare Advantage Plans have to choose a Medi-Cal plan (January 2015 start date)*
• SPDs not already in a Medi-Cal plan choose one by birth month (August 2014 start date)
*July – January in January, then by birth month
Most beneficiaries will receive three notices
90 Day 60 Day 30 Day ENROLLMENT
6/1/14
10/1/14
7/1/14
11/1/14
8/1/14
12/1/14
ENROLLMENT 9/1/14
ENROLLMENT 1/1/15
September DOB
January
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www.NSCLC.org 21
90 Day
60 Day
30 Day
• Informational Notice
• Notice with Default Plan • Guidebook • Choice Booklet and Choice Form
• Final Reminder Notice
When
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90-Day Medi-Cal Managed Care Notice
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60-Day Medi-Cal Managed Care Notice
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90-Day Cal MediConnect Notice
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60-Day Cal MediConnect Notice
What can you do?
• Influence program development
– Stakeholder meetings
– Talk to plan
– Legislative advocacy
• Prepare to provide counsel
• Report problems
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Local advocates can help individuals
• HICAP
1-800-434-0222
• CCI Ombudsman
1-855-501-3077
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Want to know more? • NSCLC Duals Website
– Advocate’s Guide
– News
– Sign up for alerts
http://dualsdemoadvocacy.org
• Contact us:
– Amber Cutler – [email protected]
– Denny Chan – [email protected]
Wrap Up
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• Disability Rights Education & Defense Fund (DREDF)
- www.dredf.org
• Department of Healthcare Services
- www.calduals.org
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