1. Who do I bill when my patient’s Medicare and Medi-Cal benefits are separate?
For patients who choose to keep their Medicare and Medi-Cal separate, physicians will need to continue to bill Medicare and Medi-Cal separately. In CCI Counties, Medi-Cal crossover claims go to the plans and not the state. Physicians can never balance bill dual eligible patients.
For more information about how payment works for physicians serving beneficiaries in Medicare and a Medi-Cal plan, please see the physician payment fact sheets.
2. How do I submit crossover claims to Medi-Cal plans?
For beneficiaries that are in Medi-Cal plans, Medicare should be billed as usual. Medicare will pay 80 percent of the Medicare fee schedule. The 20 percent copay cannot be billed to dual eligible patients. Instead, these “crossover claims” must go to the patient’s Medi-Cal plan, which will pay any amount owed under state Medi-Cal law. Since 1982, state law has limited Medi-Cal’s reimbursement on Medicare claims to an amount that, when combined with the Medicare payment, does not exceed Medi-Cal’s maximum payment for similar services. Consequently, if the Medi-Cal rate is 80 percent or less than the Medicare rate for the service rendered, Medi-Cal will not pay anything on these crossover claims.
The CMS Coordination of Benefits Agreement (COBA) Program allows crossover claims to go directly to the Medi-Cal plan after the claims have been submitted to Medicare. As most Medi-Cal plans are not yet participating in this automated process, this chart outlines how Medicare providers should submit their Medi-Cal claims to each plan.
Providers should use the Medi-Cal eligibility verification system to identify a patient’s Medi-Cal plan. Learn more about this system at www.Medi-Cal.ca.gov/Services.asp.
Physicians do not need to be contracted with a Medi-Cal plan’s network to submit a crossover claim.
3. Can I keep my patients when they join Cal MediConnect?
If your patient joins a Cal MediConnect plan and you are in the plan network, your patient may request to continue seeing you by contacting the health plan’s Member Services. If your patient joins a Cal MediConnect plan and you want to join the plan’s network, contact the health plan in your county. Please note that most health plans contract with IPAs and medical groups.
If your patient joins a Cal MediConnect plan and you remain out-of-network, continuity of care allows you to continue seeing your patient for up to 12 months, if you and the plan agree to terms. After the continuity of care period, you likely will have to contract with the Cal MediConnect plan to continue seeing your patient.
If your patient is in Original Medicare (fee-for-service) or a Medicare Advantage plan and joins a Medi-Cal plan, you may continue seeing that patient as usual. You do not need to contract with the Medi-Cal plan to continue seeing your patient.
4. What are the steps for processing Continuity of Care requests?
Cal MediConnect plans must attempt to determine if there are continuity of care needs during the Health Risk Assessment process that takes place soon after enrollment. Alternatively, enrollees, their authorized representatives or their physicians can make requests using the following steps:
1. The enrollee advises the physician that s/he has enrolled in a Cal MediConnect plan and determines whether or not the physician is part of the plan’s network. OR: The physician, upon checking the enrollee’s eligibility, advises the enrollee that s/he is enrolled in a Cal MediConnect plan and informs the enrollee whether or not the physician is part of the plan’s network.
2. If the physician is not part of the plan’s network, the enrollee, their representative or the physician contacts the Cal MediConnect plan and tells the plan that they want to continue treatment based on the pre-existing relationship.
• Plans must allow continuity of care requests by phone.
• It is the plan’s responsibility to first attempt to validate the pre-existing relationship through Medicare claims data before requesting evidence from the enrollee or provider.
3. The Cal MediConnect plan works with the physician and makes a good faith effort to determine:
• Whether the physician will accept the higher of the Medicare or plan rate for services, and
• Whether there are quality issues that would prevent the physician from being eligible to participate with the plan for this enrollee.
If an agreement is reached between the Cal MediConnect plan and the physician, the enrollee can continue receiving Medicare services from the physician for up to 12 months. At the discretion of the Cal MediConnect plan, this continuity of care period may be extended.
5. How am I involved with the care coordination of my patients in Cal MediConnect?
• Health Risk Assessment
All people enrolled in a Cal MediConnect plan are offered a Health Risk Assessment. The assessment is designed to determine what health care and social supports the patient needs and to identify existing gaps in care or continuity of care needs. Health Risk Assessments identify an enrollee’s primary, acute, long-term services and supports (LTSS), behavioral health and functional needs. The results of the assessment are shared with the enrollee and their health care providers. In some cases, you may automatically receive the results for your patients. You can always request your patient’s HRA results.
• Interdisciplinary Care Team
As a physician, you play a key role in the Interdisciplinary Care Team (ICT). The ICT provides the infrastructure for receiving and sharing information about your patients and makes it easier for your patients to get the various services and treatments they need. The core team members will be the enrollee, the primary care provider, and the enrollee’s Cal MediConnect plan Care Coordinator. Depending on the enrollee’s desires and circumstances, the ICT may also include specialty physicians, a hospital discharge planner, nursing facility representative, physical therapist, social worker, personal care services provider, family member, and relevant social and supportive service providers.
• Care Coordinators
Cal MediConnect plans provide enrollees with Care Coordinators. These coordinators will either be licensed medical professionals or overseen by a licensed medical professional. Care Coordinators do not replace the important role of physicians in directing care for patients, but can help provide the case management support and smooth flow of information that can reduce administrative burdens for physicians’ offices. The Care Coordinator is a key point of contact for the enrollee and their providers about care coordination.
• Individualized Care Plan
Physicians can help develop an Individualized Care Plan (ICP) for their patients as a member of the Interdisciplinary Care Team (ICT). The plan must reflect the enrollee’s specific goals, needs, and preferences, identifying what services and supports an enrollee needs, how the ICT will help the enrollee access those services and supports, and will include measurable objectives and timelines to meet an enrollee’s needs.