“Dual Eligibles,” “Duals,” and “Medi-Medis” are all phrases that are used to describe a class of beneficiaries who qualify for coverage under two separate governmental health care programs: Medicare and Medicaid (or Medi-Cal as it is known in California). Medicare is a program funded and managed by the federal government. Medicaid is a state-driven program that is partially funded by each state with support from the federal government as well. Both are under the oversight of the Centers for Medicare and Medicaid Services, or CMS, in Baltimore, MD.
Medicare is a program currently providing benefits for those over 65 years of age and for those under 65 who qualify with certain disabilities. Medi-Cal is a program that provides benefits to folks who fall below certain income thresholds.
In the nearly 50 years since both programs were enacted, each program has grown substantially, providing overlapping services to overlapping populations. Yet they have remained completely separate, with different rules and coverage requirements. At best, this makes the health care process sometimes difficult to navigate for those beneficiaries covered by both programs. At worst, it results in disjointed care for a vulnerable population that requires some of the highest utilization of health care services.
Policymakers now have decided that healthcare for the Duals is much better coordinated through managed care plans where doctors, hospitals, pharmacists and medical suppliers can all work together. Hence, going forward the way Dual eligible beneficiaries get their healthcare is changing. State and Federal governments are implementing programs that combine all healthcare related benefits through a single managed care plan. In addition to California, Illinois, Washington, Texas and Colorado are all planning to move Duals into managed care plans at different times over the next couple of years.
Let’s take a look at the Duals program that is developing in California.
Eligibility
Only certain California counties are participating in care coordination programs for Duals. Most adult fee-for-service Duals residing in these counties will be eligible. There are however, certain groups that are not eligible and those may include:
- Under age 21
- Those with other health coverage
- Share-of-cost or spend-down beneficiaries
- Medicare Advantage and Special Needs Plan members (exempt in 2014)
- PACE or AIDS Healthcare Foundation enrollees
- Individuals living in select rural zip codes
- Receiving services through a regional center, state developmental center, or intermediate care facility for the developmentally disabled (ICF-DD)
- Beneficiaries in select waiver programs
Enrollment
Enrollment for currently approved plans is county-specific. Duals will be able to choose how they want to access their Medicare benefits. They can voluntarily enroll in a managed care plan which integrates their Medicare and Medi-Cal benefits or they can choose to “opt out” and keep their Medicare the way it is today with no change. Regardless, Duals must still enroll in a managed care plan to use their Medi-Cal benefits. There is no way to opt out of managed care for Medi-Cal.
If no choice is made by the Dual, the State of California will “passively enroll” or automatically assign them to a managed care plan to handle both Medicare and Medi-Cal covered benefits. Most eligible Duals will be enrolled this way. California will try to match Duals to the managed care plan that covers their primary doctor or healthcare provider. Linking individuals to plans based on provider relationships may not be possible in every case. There will be instances where Duals will have to find new primary care providers if their existing ones are not contracted with a plan.
State and County Specific Program Details
Care coordination activities for Duals in California vary by County. The details provided below are based on the most up to date information available as of June 4, 2014.
California Coordinated Care
California has the Coordinated Care Initiative (CCI) or Cal MediConnect program. There are eight participating counties and twelve contracted health plans. Implementation is county-specific according to the following:
- San Mateo County: Passive enrollment begins no sooner than April 1, 2014. All eligible Duals enroll at once. Health Plan of San Mateo is the only health plan choice.
- Riverside & San Bernardino Counties: Voluntary enrollment begins no sooner than April 1, 2014. Passive enrollment begins no sooner than May 1, 2014. April and May birthdays enroll in May then it follows enrollment schedule by birth month. Inland Empire Health Plan and Molina Healthcare are the health plan choices.
- San Diego County: Voluntary enrollment begins no sooner than April 1, 2014. Passive enrollment begins no sooner than May 1, 2014. April and May birthdays enroll in May then it follows enrollment schedule by birth month. Care 1st, Community Health Group*, Health Net and Molina Healthcare are the health plan choices.
- Los Angeles County: Voluntary enrollment begins no sooner than April 1, 2014. Passive enrollment begins no sooner than July 1, 2014 for CareMore*, Care 1st, Molina Healthcare and Health Net. LA Care will be eligible for passive enrollment once it improves its Medicare quality ratings. It is not known when this will happen. July birthdays enroll in July then it follows enrollment schedule by birth month. Those are the five health plan choices.
- Orange County: Passive enrollment begins no sooner than January 1, 2015. January birthdays enroll in January then it follows enrollment schedule by birth month. Cal-Optima is the only health plan choice.
- Alameda County: Passive enrollment begins no sooner than January 1, 2015. January birthdays enroll in January then it follows enrollment schedule by birth month Alameda Alliance for Health and Anthem Blue Cross are the health plan choices.
- Santa Clara County: Passive enrollment begins no sooner than January 1, 2015. January birthdays enroll in January then it follows enrollment schedule by birth month. Santa Clara Family Health Plan and Anthem Blue Cross are the health plan choices.
(*SHC is not contracted with these plans)
Changes and updates occur frequently and may come at any time. Visit Shield HealthCare’s website, www.shieldhealthcare.com, to stay on top of any new developments.
