Consumer protections are a cornerstone of the Cal MediConnect program. The following protections are described in the MOU between the federal and state governments that outlines the program’s parameters.
Continuity of Care
Participating health plans will be required to provide access to necessary services and providers for a transition period of up to six months for Medicare services if certain criteria are met1 and a period of up to twelve months for Medi-Cal services if certain criteria are met.2 Plans are required to perform an assessment within 90 days of beneficiary enrollment to identify existing providers and establish a plan regarding continuity of care, if applicable.
Enrollment Assistance and Options Counseling
Individuals eligible for Cal MediConnect will be able to access independent enrollment assistance and options counseling to support their enrollment decisions. CMS and the Administration for Community Living (ACL) have set aside funds to support outreach, education, and options counseling.
Ombudsman
California will establish an Ombudsman office to help resolve issues between Medi-Cal managed care members and participating health plans. As of the date of publication, no additional details are available about the development of this office.
Person-Centered, Appropriate Care
All medically necessary services must be provided to enrollees in an appropriate manner that recognizes cognitive and physical functional status, language and culture, and caregiver involvement (to the extent desired by the beneficiary). Services are to be received in an appropriate setting with emphasis on the home- and community-based environment.
Americans with Disabilities Act (ADA)
Participating health plans must be in compliance with the ADA and the Civil Rights Act of 1964. Plans will be required to accommodate the communication needs of beneficiaries, including making interpreters available as needed. The MOU cites the Olmstead decision, indicating that the state and CMS will provide ongoing monitoring to ensure that those beneficiaries needing LTSS receive such services in the “care settings appropriate to their needs.”
Participant Communications
All communications with prospective enrollees, such as mailings regarding enrollment into Cal MediConnect, will be available in alternate formats, threshold languages and a sixth-grade reading level.
Consumer Participation on Plan Governing and Advisory Boards
CMS and the state will require participating health plans, as part of the three-way contract, to include beneficiary and community input on plan activities related to program management and enrollee care. This may include beneficiary participation on plan governing boards or quality review committees. Each plan must also establish at least one consumer advisory committee, with monthly meetings, to provide input to the governing board. The advisory committee must reflect the diversity of the enrollee population in the plan, including people with disabilities.
Additional Consumer Protections
Other beneficiary protections detailed in the MOU include the following
- Participating health plans must hire sufficient numbers of customer service representatives to respond to enrollee inquiries and complaints within a period of time as defined by CMS and the state.
- CMS and the state will also staff call centers in sufficient numbers to respond to beneficiary inquiries and complaints.
- All plans must ensure the privacy and security of enrollee health records.
- Plans are not permitted to charge premiums or any cost-sharing for Medi-Cal services, and copays charged for pharmacy must not exceed that established by CMS under the Part D low-income subsidy or Medi-Cal cost-sharing rules.
- Providers may not bill patients for any portion of the covered service, known as “balanced billing.”
You can download the following fact sheets related to consumer protections
- CCI Consumer Protections: (August 30, 2012) A summary of all the consumer protections included in the CCI.
- CCI Legislative Reporting Requirements: (August 30, 2012) A summary of the legislative reporting requirements for the CCI.
- CCI Stakeholder Engagement Requirements: (August, 30, 2012) Summary of stakeholder engagement requirements.
[1] The enrollee must demonstrate an existing relationship with the provider prior to enrollment, the provider must be willing to accept payment from the participating health plan on the current Medicare fee schedule, and the plan would not have otherwise excluded that provider from its network due to quality or other concerns.
[2] The enrollee must demonstrate an existing relationship with the provider prior to enrollment, the provider must be willing to accept payment from participating health plan based on the plan’s rate of service or the applicable Medi-Cal rate (whichever is higher), and the plan would not have otherwise excluded that provider from its network due to quality or other concerns. This policy does not apply to IHSS providers, durable medical equipment, medical supplies, transportation, or other ancillary services.
Background Documents on Consumer Protections
Consumer Perspectives
- Adding Perspective: A Summary of Conversations wtih Dually Eligible Beneficiaries (Harbage Consulting, 2011)
- Focus Group Summary: Beneficiaries in Alameda, San Bernardino and Riverside Counties * (Thomson Reuters, 2011)
* As of November 2014, the CCI will no longer be moving forward in Alameda County.
Disability Rights California
- Dual Eligibles Due Process Proposal (April 2012)
- Principles for LTSS in Managed Care (April 2012)
IHSS Consumers Union
From Across the Nation
- Experienced Voices: What Kind of Care Works Best for Dual Eligibles? (AARP Public Policy Institute/December 2011)
- Experiences of Medicare-Medicaid Enrollees: Findings from Focus Groups in Five States (Thomson Reuters Healthcare/December 2011).
- Integrating Care for Dual Eligibles: What Do Consumers Want? (Webinar from the Alliance for Health Reform and AARP Public Policy Institute/December 2011)