Passage of the Coordinated Care Initiative in late June marks an important step toward transforming California’s health care delivery system to better meet the needs of some of the the state’s most vulnerable residents who too often receive fragmented and uncoordinated care.
Budget trailer bill legislation — SB 1008 and SB 1036 — lays out a road map to integrate Medicare and Medi-Cal service delivery and financing so more Californians receive the right services, in the right place, at the right time. It will help people live longer in their homes and communities. The goal of this effort is to improve care, while at the same time creating greater value for Medicare and Medi-Cal.
The legislation included the following key changes:
- Eight Counties. The final initiative scales back implementation of the demonstration to eight counties. Long-term services and supports (LTSS) will be integrated as managed care benefits only in those eight counties, versus statewide as originally proposed. The eight counties are:
- Greater Preparation Time. While the demonstration was scheduled to start in January 2013, implementation now will occur no sooner than March 1, 2013 but no later than June 1, 2013, to provide more preparation time.
- Population Carve Outs. The legislation excludes additional dual eligible beneficiaries from passive enrollment, including those under age 21, those with certain medical conditions, such as end-stage renal disease, and people in existing home- and community-based waiver programs. The department is analyzing the final list of excluded populations to project the number of beneficiaries eligible for passive enrollment.
- Stronger Protections. About one-fourth of the legislation is dedicated to protections that ensure beneficiaries are adequately informed of their options and their continuity of care is guaranteed. It requires strong readiness criteria for the health plans and the Department of Health Care Services before implementation next year.
As it moves toward implementation, the Department of Health Care Services will stay focused on:
- Lessons Learned. California’s recent transition of Seniors and Persons with Disabilities to managed care has helped develop important protections for dual eligible beneficiaries, such as continuity of care.
- Access to Care. Beneficiaries enrolled in the demonstration will have greater access to the full continuum of services needed to help them live in the community and avoid institutionalization.
- Strong Oversight & Monitoring. Several state departments will join forces to more effectively oversee the demonstration health plans and report regularly to the California State Legislature.
Considerable work remains to ensure beneficiaries will have a smooth transition into these new integrated delivery systems. Providers will receive reimbursement rates sufficient to maintain access to care. Savings under the demonstration are intended to be achieved through shifts in utilization, and not through reduced rates to providers.
Toby Douglas, the director of the Department of Health Care Services, has requested stakeholders’ continued engagement as the Department shift its focus to implementation. An ongoing two-way dialogue with stakeholders is essential to ensuring success in this undertaking, he said. The Department will continue fostering a transparent process and keep you informed through regular email updates and through this website.
Do you have any of this information available on this site in Spanish language?
Thanks.
They will not be happy until the Government is in total control of our lives.Not to mention the people making these choices at the Government level are novices and politicians.
Thanks for the great question. This site doesn’t have any information in Spanish yet. The Department of Health Care Services will develop outreach and notice materials in multiple languages, including Spanish, and they will be linked to from this site.
Are you going to be sending information to home health agencies how to set contract with HMO providers for this dual program? Once an elderly sign into an HMO can they cancelled if not satisfy with the services? and how long would it take to desinrol. My understanding is that some elderly persons at this time are not able to cancel HMO.
Maria
Being able to stay in the community longer benefits the individual. Financially it benefits those who fund the programs as it is a lower cost option overall. A win-win.
How dare the state claim that Managed Lack of Care is better for us! This is all about the money, not the beneficiary’s. When an insurance company or medical group is getting paid and gets to determine what care one “needs” it is a rigged game. We are not idiots. Most of us have long term doctors, I’ve been with mine for 15 plus years. I have absolute trust in her. Now to tell me I have to go to (into managed care) just because I have the misfortune to have become disabled and am low income. I doubt you would do this to your mother. I absolutely do not believe the heartfelt tales of elderly and disabled clients that managed lack of care has been a lifesaver to them. It is cruel and unusual punishment to those whose only crime is to old, disabled and poor. Shame on all of you.
You are absolutely right,I agree with you Pam
Totally agree with Pam.
You are right!! This is all about money! Managed care “capitation” means that Stage 4 ovarian cancer patients like me are more profitable to the managed “care” industry dead rather than alive — chemo and hospital stays are expensive! The managed care company (with “triage” clerks in India) can deny or delay treatment and force me to go through the lengthy appeal process; by decision time I’ll be dead! I dread “enrollment time” next March (it looks like enrollment is mandatory for the Medi-Cal part and you can opt out ONLY from the Medicare part). I may move to a non-demonstration county and live in my RV on the streets; homelessness is becoming an option, I don’t want to die because of someone’s business decision.
I am in a sad predicament where IHSS and my managed care were at complete odds with one another directive wise. There are not competing markets unless you look at a dead person as a good profit margin.
Please consider not forcing managed care onto participants. I have joined Kaiser pre-emptively to ensure my FUTURE care is taken over by at least a group large enough in my state to work with me at 37 years old, instead of chopping block like the rest of the 55+ population I ride in taxis with. They are treated like crap, and I’m right with them.
Try to vote and stop the nightmare Los Angeles. Outsourced small local hospitals do NOT have control of your complex case. Anyone can be deemed “complex” and relegated into a threat by supposed case managers that all duplicate themselves? See LA county for more homeless ideas, I’m with you and leaving too. Thanks!
Totally agree with Pam. She speaks the truth for many low income elderly citizens. My mother is one of them Thank you, Pam…
Managed care has been a nightmare for me and my son who has severe autism and mental retardation. We have seen a different doctor each time we visit the office. One doctor prescribed medicine that could cause mental/mood changes. My son is nonverbal and the health plan would not speak to me even though I am his appointed representative. The customer service staff are rude and you can only use county doctors and facilities. He has not been able to get the care and services he need. I am waiting on the approval of his medicare and I will drop the medi-cal. I prefer to pay what ever to get the care he needs.
Mostly everything is about money- do you know WHY your doctor of fifteen years will not see you if you go into managed care? It’s probably because she won’t make enough to see you. And it’s not worth their time. Think about it. Most doctors are not accepting Medi-Cal or Medi-Care without a plan- call around and ask!!
Actually my doctor WILL NOT BE ALLOWED to see me. Sac County victims will all be forced into Molina “Health” Clinics. She’s already not being paid to see me. Medi-Cal lowers their rates every year and I’ve never heard of Medicare going up. Along with requiring a doctor/practice to take on a certain percentage of their patients having Medi- Cal if they take even one. This is why sole practitioners rarely see Medi-Cal people. With overhead, billing, staff, equipment and for the younger doctors, decades of student loans they actually lose money seeing us.
As many of you know also, due to the complicated deductibles, co-pays, billing, etc, most doctors will also not take strictly Medicare. I came up against that when I still had some money in the bank and not eligible for MediCal. Most require a secondary insurance of some type, that way they do get paid a pittance and don’t have to turn you away for owing too much. Remember they do have bills and employees to pay…
God, what ever happened to the insurance I had in the 70’s and 80’s! I paid a reasonable priemium, the insurance company paid the doctor, hospital and pharmacy a reasonable rate too. No copays, deductables, ect. My Doctor and I made the medical decsions, not some fat cat that’s never cracked a medical book. To think this all started here in CA – the birthplace of the HMO and the only state that’s bought into this criminal behavior hook line and sinker.
Pam. In most cases you can choose from multiple carriers depending on who your doctor has contracted with. You can (and should) talk with a licensed agent who knows your area and they will do all the work for you on finding out which carriers your doctor is contracted with, what specific needs you have and what options are available to you. I’m not saying it’s perfect but it is one way of controlling run-away cost that the State can no longer afford. Check out http://www.Medicare.gov to review plans that are available in your area and compare benefits and Star ratings.
Why should the poor receive richer benefits and more freedom than the middle class who has been economically forced to join Medicare Advantage? It’s time for the poor to stop feeling so entitled.
I agree with you Pam. The CCI is a death sentence for me. When I was in an HMO two years ago, they constantly turned down vital tests, treatments, and drugs for me. My doctors had to fight to get me specialists, it took hours of their time. They gave up and told me they can’t work with HMOs. I’ve been in Original Medicare and Medi-Cal now the past year and it was heaven. I got the treatment I needed to survive. Now, with CCI, I will die. Thank you so much, Governor Brown.
If the managed care plans are going to benefit patients that much, won’t the Medi-medis just line up to join? Why is passive enrollment being forced on a population that is already burdened with balancing the state budget in so many other ways and now is being dumped into a system that is untested and probably unnecessary, except to increase profits for healthcare plans and/or providers. Roll them out, see how they suit the dual-eligible population AND THEN allow choice to dictate how healthcare is received. Fee-for-service Medi-Cal is still more widely accepted and in many cases, patients have been receiving care for many years and are more than happy with it. Have you seen the data for patient satisfaction of the Special Needs Plans under MEdicare Advantage? They are abysmal in most areas of patient satisfaction and these are the very same plans that are being touted as dual managed care plans…Come on, tell the truth…
The passive enrollment process that the state is using is extremely disconcerting because many of these patients may fail to respond to the letter notifying them of this program and their RIGHT to opt out of it. When they fail to respond, they will automatically be placed into a Medicare HMO plan. I am sure you relaize what that will mean in terms of patient care and possible reimbursement for services by doctors. Please remember that you can opt out of this program on the Medicare side! Supposedly, letters will be sent to those who are dual eligible by year’s end. Make sure to pass on to others the negative impact of having Medicare being taken over by an HMO. Also, inform other Medi/Medi patinets that they can opt out of this program.
You can opt out of the specific dual program they are hyping, but my understanding of the bill is that they will be forcing all of us Medi-Medi’s into managed care. As I’ve said above, this is a death sentence for me. I know, I’ve had managed care before. They refused an EKG for me immediately after I had a heart attack! This is pure evil. Hyping that they are increasing coverage for us older folks while in reality cutting our chances of survival and health.
Passive enrolment should not apply to patients in skilled nursing facilities and/or those that have dementia or chronic mental illness!
Dis-enroll from Medi-Cal, keep LIS for RX, and buy a Medicare Supplement plan F. If it’s a huge deal to keep doctors that are in several different medical groups you’ll have to spend a little money to keep that flexibilit going forward.
Not sure what rock you all live under, but the state doesn’t have enough working people to tax so they can pay your rent, electric, food, insurance and everything else anymore so you better figure out a way to make $300 a month to spend on a Medicare Supplement Plan F to keep your frredom of choice. I don’t think that’s too much to ask when the program is going to lower costs to the state and feds drastically and HMO’s won’t be a problem for many of the people.
P.S. In case you don’t know a Medicare Supplement does what Medi-Cal does. It pays what Part A and Part B don’t cover. If you get that which is $300 a monthh for someone under 65 on disabilityand $140 a month for someone 65, it will be the same as having Medi-Cal.. Keep LIS for RX. Simple solution.
I work for one of the 21 RC’s. Please consider that the plan for the 6 month window to retain only primary and specialists should include pharmaceutical, DME and medical supply companies. The switch from straight MediCal to an HMO has been a nightmare for many of our medically fragile/physically disabled clients with an inability to get a timely appointment with the Primary, obtain needed equipment, supplies and meds. Also, Can we be assured that the HMO will assign case managers to RC clients to assist them with their complex needs?
LOL complex needs is right. I had an outsourced company send in two off site, in other counties case managers. One called my pcp Dr. Ho no matter how many times I corrected them, It’s DR HAN OK! And the replacement person who was mandated to show up next in line was busy telling me if I didn’t convince a conservative korean doctor who was a diplomat to prescribe me medical mj in a pill that I would do better off in an institution.
Yeah, Reported them both. Done mixing my IHSS with concerned outsourced case management. Ready for the new way, not nec this new way.
Question: After Medicare demonstration starts in June 2013, if a patient opts out, what will happen with their deductibles and 20% copays. Will Medical Managed care pay for them or it will be patient’s responsibility?
If someone opts out of the demonstration and chooses not to have his Medicare benefits coordinated by a participating health plan, he will still have to enroll in a Medi-Cal health plan. The Medi-cal health plan will pay the deductibles and 20% copayments just as the state would. Enrolling in a Medi-Cal health plan will not affect the the person’s choice of Medicare providers.
Come again? So if I have to enroll in a Medi-Cal health plan to get out of this garbage, … I’m still in a health plan! Just a different one.
I think you are mistaken Sarah. Medi-Medi’s do not have a separate Medi-Cal and Medicare doctor. If you are in a “health plan” you have to see the doctors on their list or clinics. That is a given. Hence the “Plan”. The plan will not pay the co-pays, etc when you see providers not on their list. They won’t pay anything.
As a medical doctor I have been taking care of many of these dual seniors for the past quarter of a century. Simply put, I am very afraid that these sudden and massive shift of millions of senior citizens to HMO’s will cause tons of medical disasters. I predict that by next June many seniors in these “Demonstration Counties” will be denied access to their old trusted doctors and face tremendous delays in getting into their newly assigned HMO system. Thus many of these medically fragile seniors unfortunately will not be able to get the needed care and or prescriptions in time, resulting in urgent medical situations and end up in an emergency room which they will find flooded with other people in the similar situations.
After witnessing these medical and social nightmares, eventually the state will find out that taking care of these newly created medical disasters will end up costing the society much more than the supposed savings through the HMO-system.
I agree, what happen to our country? Where is the freedom? We are more and more changing into a socialistic society! HMO simply do not work, how they make money is by suppressing our right to seek medical help. It is such a hassle to get treatment authorization for this HMO, they jus play game, and even if they authorized the treatment, the physicians or medical facility would have hard time to collect the fees. I have been in this medical for over 20+ years, the HMOs only want to make profit, and they have no concern for the patients health
There have way too many immigrants and californians getting a free ride all of these years. It is now time to pay the piper. Taxes are already too high for the working and upper classes. Something has got to give. For many years, the middle class elderly have joined Medicare Advantage and they got adjusted to it. I don’t see why the Medi-cal poor couldn’t do it too. If they don’t want to do it, then they should go PURCHASE a Med supplement like everyone else has had to do. then you can see any doctor that you please.
I think many of these fews are a litte extreme…A socialist society??
Really? If you are copmlaining about the HMOs you should also be complaing about Fee For Service Medicare and Medi-Cal. After all, What is Medicare but socialized medicine for the elderly?
Yes…it IS about money but, what isnt? So is playing Bingo every Thursday.
The bottom line is our State going broke and while the causes are far to many to mention here, why shouldn’t everyone do their part to help curb costs? I would rather have medicare under an HMO than no Medicare at all.
Please read Craig’s post from Dec. 12th…the guy makes sense.
Question: Will Pharmacy benefits move to Managed Care or will they remain in Medicare Part D for members involved in the Dual Demonstration Project?
Pharmacy benefits will be available through Part D offered by the participating demonstration health plans.
So when the Medicare-MediCal or “duals” patient receives the letter, he can opt out of the duals demonstration. If he does not respond, he will be assigned to a Medicare HMO plan. So in order for the physician to “keep” his current duals patients, the physician must be in his county MediCal network (contracted with his County) and tell his patients to answer the letter and select opt out. The key for both the doctor and the patient is educating the patient to Opt Out and not to accept passive enrollment in an HMO.
So when the Medicare-MediCal or “duals” patient receives the letter, he can opt out of the duals demonstration. If he does not respond, he will be assigned to a Medicare HMO plan. So in order for the physician to “keep” his current duals patients, the physician must be in his county MediCal network (contracted with his County) and tell his patients to answer the letter and select opt out. The key for both the doctor and the patient is educating the patient to Opt Out and not to accept passive enrollment in an HMO.
I have already been subjected to lack of care and loss of continuity of care and waiting for months for care for possible recuranc of breast cancer this scares the hell out of me can’t opt out no money to pay for what meicare does not pay I have no choise not fair. Why don’t they just kill me niow it would be quicker and less painful? If they don’t I probably will. Can’t take this lack of care emotionaly. Don’t kniow what to do.
I have already been subjected to lack of care and loss of continuity of care and waiting for months for care for possible recuranc of breast cancer this scares the hell out of me can’t opt out no money to pay for what meicare does not pay I have no choise not fair. Why don’t they just kill me niow it would be quicker and less painful? If they don’t I probably will. Can’t take this lack of care emotionaly. Don’t kniow what to do.
Duals have the best insurance available. Period. Importantly, enrolling in a Medicare Advantage plan will only increase their benefits – by a huge amount. At the same time, enrolling Duals will also reduce the massive amount of fraud being hoisted on tax payers who have to purchase their own insurance to get a fraction of the benefits duals get.
Too bad, for the most part, Duals are amazingly spoiled to figure it out. Hey Duals, in case you haven’t heard, California can’t pay its bills. It is insolvent. That means broke. Like the previous poster wrote, if you don’t like it, go purchase a Medicare Supplement plan for $300.00 per month (plus a Part D plan) and quit complaining.
Harry, I live on $1292 a month SSC retirement, period. I am a diabetic, post heart attack, cancer patient. Sorry to complain, but I will die with this new CCI. I am an author, and if I get lucky I can support myself again with my work, but unless and until then, I am at the mercy of the State. I don’t have the $300 per month you suggest.
Duals have the best insurance available. Period. Importantly, enrolling in a Medicare Advantage plan will only increase their benefits – by a huge amount. At the same time, enrolling Duals will also reduce the massive amount of fraud being hoisted on tax payers who have to purchase their own insurance to get a fraction of the benefits duals get.
Too bad, for the most part, Duals are amazingly spoiled to figure it out. Hey Duals, in case you haven’t heard, California can’t pay its bills. It is insolvent. That means broke. Like the previous poster wrote, if you don’t like it, go purchase a Medicare Supplement plan for $300.00 per month (plus a Part D plan) and quit complaining.
Harry, I live on $1292 a month SSC retirement, period. I am a diabetic, post heart attack, cancer patient. Sorry to complain, but I will die with this new CCI. I am an author, and if I get lucky I can support myself again with my work, but unless and until then, I am at the mercy of the State. I don’t have the $300 per month you suggest.
I’m just beginning to explore this issue but, if I understand correctly, I can opt out and keep standard Medicare but will be assigned an HMO for my Medical portion. This will mean that if I see my Medicare doctors that are not part of the Medical HMO, I will have to pay the 20%. Being on Medi-Medi means I’m low income. Obviously, I do not have the money to do that. This program touts continuity of care. I have that now but putting me in an HMO I lose that. Rebel, contact your assembly person.
Hello Trudi,
Your understanding is only partially correct. Yes, you may opt out of the new program to combine your Medicare and Medi-Cal benefits. Yes, you will then still have to join a Medi-Cal health plan for any Medi-Cal benefits. You will not have to start paying any Medicare costs that you currently don’t pay today. The Medi-Cal health plan will pay your Medicare deductibles and any portion of the Medicare bill that the State currently plays today. Your provider’s billing company will just send the bill to the Medi-Cal health plan for payment like they send it to the state today. The Medi-Cal health plan may also be able to provide you with transportation and supplemental medical equipment. This does not mean the Medi-Cal health plan will tell you which Medicare doctors and hospitals you can go to. You can still see the Medicare doctors and hospitals you see today.
Helllooo! Don’t think a health plan is going to pay other doctors not in their plan to see you. That’s not the point of the company.
Smells like perhaps you think we are these helpless little things that can be conned into anything. If what you say is true (notice the absence of the held breath) do post it prominently on the CalDuals home page site and on this board COMPLETE WITH Full LEGISLATIVE AND LEGAL CITATIONS with nothing skipped, blacked out, etc.
I’m just beginning to explore this issue but, if I understand correctly, I can opt out and keep standard Medicare but will be assigned an HMO for my Medical portion. This will mean that if I see my Medicare doctors that are not part of the Medical HMO, I will have to pay the 20%. Being on Medi-Medi means I’m low income. Obviously, I do not have the money to do that. This program touts continuity of care. I have that now but putting me in an HMO I lose that. Rebel, contact your assembly person.
Hello Trudi,
Your understanding is only partially correct. Yes, you may opt out of the new program to combine your Medicare and Medi-Cal benefits. Yes, you will then still have to join a Medi-Cal health plan for any Medi-Cal benefits. You will not have to start paying any Medicare costs that you currently don’t pay today. The Medi-Cal health plan will pay your Medicare deductibles and any portion of the Medicare bill that the State currently plays today. Your provider’s billing company will just send the bill to the Medi-Cal health plan for payment like they send it to the state today. The Medi-Cal health plan may also be able to provide you with transportation and supplemental medical equipment. This does not mean the Medi-Cal health plan will tell you which Medicare doctors and hospitals you can go to. You can still see the Medicare doctors and hospitals you see today.
Helllooo! Don’t think a health plan is going to pay other doctors not in their plan to see you. That’s not the point of the company.
Smells like perhaps you think we are these helpless little things that can be conned into anything. If what you say is true (notice the absence of the held breath) do post it prominently on the CalDuals home page site and on this board COMPLETE WITH Full LEGISLATIVE AND LEGAL CITATIONS with nothing skipped, blacked out, etc.
Once a Medi-Medi is auto-assigned and finds that his her providers are not contracted, will they have the ability to change to another Plan that may have more of their providers “in network”? Any time they wish or only at certain times of the year?
The state’s proposal is that a dual eligible may opt out of the demonstration altogether or change demonstration health plans any month.
The fact that a person is low income or is qualified for medi-cal create a special election period. a special election period is a situation of special circumstances allowing that person to change from 1 plan to another at any time during the year. The change however will not go into effect until the first of the following month.
Once a Medi-Medi is auto-assigned and finds that his her providers are not contracted, will they have the ability to change to another Plan that may have more of their providers “in network”? Any time they wish or only at certain times of the year?
The state’s proposal is that a dual eligible may opt out of the demonstration altogether or change demonstration health plans any month.
The fact that a person is low income or is qualified for medi-cal create a special election period. a special election period is a situation of special circumstances allowing that person to change from 1 plan to another at any time during the year. The change however will not go into effect until the first of the following month.
I am the Benefits Specialist at the San Diego Regional Center and as you know are clients are excluded from the Cal MediConnect option but many will need to select a Medi-Cal Managed Care unless they reside in an ICF facility. Today I received a call from one of our ICF Vendors who has received several letters for client’s residing in their homes. Out of the bunch, only one mentioned selecting a Medi-Cal Managed Care all others were all about the Cal MediConnect. In an effort to be proactive, how can we prevent Regional Center clients that reside in ICF’s from being erroneously enrolled in either CalMediConnect or a Medi-Cal Managed Care? I’d prefer to prevent a flood of calls to the State Managed Care Ombudsman if at all possible. Do you have any ideals on a proactive approach for resolving and alleviating massive chaos? Your assistance would be greatly appreciated.
I am the Benefits Specialist at the San Diego Regional Center and as you know are clients are excluded from the Cal MediConnect option but many will need to select a Medi-Cal Managed Care unless they reside in an ICF facility. Today I received a call from one of our ICF Vendors who has received several letters for client’s residing in their homes. Out of the bunch, only one mentioned selecting a Medi-Cal Managed Care all others were all about the Cal MediConnect. In an effort to be proactive, how can we prevent Regional Center clients that reside in ICF’s from being erroneously enrolled in either CalMediConnect or a Medi-Cal Managed Care? I’d prefer to prevent a flood of calls to the State Managed Care Ombudsman if at all possible. Do you have any ideals on a proactive approach for resolving and alleviating massive chaos? Your assistance would be greatly appreciated.
I was pushed into Molina and did’t know it until my perscription company (AARP) notified me. My neurologist is out of system. I’ve called Molina 3x asking if my continuation of care has gone through (30 mins on hold). I want medicare back and to opt out of the system!
Call Health Care Options at 1-844-580-7272 to get help with enrollment into a health plan.
I was pushed into Molina and did’t know it until my perscription company (AARP) notified me. My neurologist is out of system. I’ve called Molina 3x asking if my continuation of care has gone through (30 mins on hold). I want medicare back and to opt out of the system!
Call Health Care Options at 1-844-580-7272 to get help with enrollment into a health plan.