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Cal MediConnect Physician FAQs

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What You Need to Know About Keeping Your Patients and Billing for the Dual-Eligible Population
By the California Medical Association

In an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities, the 2012 California state budget authorized a three-year demonstration project, the Coordinated Care Initiative (CCI). The Centers for Medicare and Medicaid Services (CMS) approved the memorandum of understanding (MOU) between the State of California and CMS on March 27, 2013. CCI contains two main components:

1. Cal MediConnect, which transitions individuals who are eligible for both Medicare and Medi-Cal (dual-eligibles) away from fee-for-service and into managed care, and
2. integration of long-term supports and services into managed care.

The Cal MediConnect program transitions dual-eligibles into managed care and allows them to receive medical, behavioral, long-term supports and services, and home-and-community-based services coordinated through a single health plan.

Cal MediConnect was approved in eight counties: Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara. No more than 456,000 individuals will be allowed to enroll into Cal MediConnect. Los Angeles’ enrollment will be capped at 200,000.

QUESTIONS:

1. When will the Cal MediConnect demonstration begin?
2. Will dual-eligibles be required to enroll into a Cal MediConnect plan?
3. Are there any dual-eligible individuals who are excluded from Cal MediConnect?
4. How can my patients opt out of Cal MediConnect?
5. Will I be able to keep my patients?
6. If my patient selects a plan in which I am not contracted, can I continue to see the patient?
7. Can I request continuity of care on behalf of my patients?
8. Who do I bill and what are the reimbursement rates?
9. If my patient opts out and remains with the fee-for-service Medicare, will the crossover claim automatically forward to the Medi-Cal managed care plan?
10. If my patient opts out and remains with fee-for-service Medicare, do I need to be contracted with the patient’s Medi-Cal managed care plan to receive deductible and coinsurance payments?
11. If my patient opts out and remains with fee-for-service Medicare, can the Medi-Cal managed care plan require an authorization?
12. How do I identify a Cal MediConnect patient versus regular Medi-Cal managed care patient?
13. What options are available for Cal MediConnect patients who are having trouble finding in-network providers and/or facilities to provide care?
14. Where can patients and physicians report continuity of care or other problems?

QUESTION 1: When will the Cal MediConnect demonstration begin?

The demonstration project start date varies by county. Some counties began with a voluntary enrollment period prior to the start of passive enrollment. [“Passive” enrollment means that if a patient does not proactively select a health plan, he or she will be “passively” enrolled into a plan selected by the California Department of Health Care Services (DHCS).]

Once the passive enrollment period begins, dual-eligible individuals in all counties except San Mateo will be automatically enrolled over a 12-month period based on birth month. (San Mateo had a hard start date of April 1, 2014, rather than a 12-month rollout.) Notification will be made to participants by birth month at the 90-, 60-, and 30-day periods prior to “passive” enrollment. Patients who do not select a health plan after all three notices will be “passively enrolled” into a plan selected by DHCS.

For a list of the start dates by county and plan, see CMA’s “Duals Passive Enrollment Timeline” at www.cmanet.org/duals.

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QUESTION 2: Will dual-eligibles be required to enroll into a Cal MediConnect plan?

Dual-eligible patients in the eight affected counties have the option of opting out of a Medicare managed care plan and staying in fee-for-service Medicare, but there is no ability to opt out of enrollment in a Medi-Cal managed care plan. Participation in a Medi-Cal managed care Cal MediConnect plan is required in order to receive all Medi-Cal health benefits, including long-term services and supports.

Beneficiaries will be sent a unique “Health Plan Choice Form,” found in the middle of the Plan Choice booklet. The choice form will give beneficiaries the opportunity to opt in or out of the Cal MediConnect program.

Patients who choose to opt out of the demonstration and remain with fee-for-service Medicare can do so at any time and their fee-for-service coverage will be effective in the following month. Those who wish to opt out or switch to another plan can contact Health Care Options at (844) 580-7272.

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QUESTION 3: Are there any dual-eligible individuals who are excluded from Cal MediConnect?

Yes. Certain dual-eligible populations will be excluded from Cal MediConnect, including but not limited to:

• individuals under age 21,
• individuals with other private or public health insurance,
• individuals receiving services through a regional center, state developmental center, or intermediate care facility for the developmentally disabled,
• most individuals with a share of cost,
• individuals residing in a veterans home,
• individuals in the following rural zip codes: San Bernardino: 92242, 92267, 92280, 92323, 92332, 92363, 92364, 92366, 93592, and 93558; Los Angeles: 90704; Riverside: 92225, 92226, 92239
• individuals with a diagnosis of end-state renal disease at the time of enrollment, except in San Mateo and Orange counties.

For a complete list of the Cal MediConnect exclusions, visit the CalDuals website at www.calduals.org/wp-content/uploads/2012/08/CCI-Participating-Populations_November2013.pdf.

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QUESTION 4: How can my patients opt out of Cal MediConnect?

Federal guidelines require that individuals be allowed to opt out of passive enrollment verbally, as well as in writing. Beneficiaries can opt out by doing the following:

1. Call 1-800 Medicare.
2. Call Health Care Options at (844) 580-7272.
3. Fill out the state’s “Health Care Choice Form,” which provides two options: a. Beneficiary can enroll in a combination Cal MediConnect plan (Medicare and Medi-Cal benefits from the same plan); b. Beneficiary can elect to keep original fee-for-service Medicare and enroll only in a Medi-Cal managed care plan for their Medi-Cal benefits.

Patients should receive their choice form within the Plan Choice booklet shortly after receiving the 60-day notice.

CMA has created sample letters for physicians to provide to patients on their options with the Cal MediConnect program, including information on whether the physician participates with any of the Cal MediConnect plans that can be customized by the practice, available at www.cmanet.org/issues-and-advocacy/cmas-top-issues/cal-mediconnect.

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QUESTION 5: Will I be able to keep my patients?

Yes, there are a number of scenarios in which you will be able to keep your patients, even if you do not contract with their Medi-Cal managed care plan. Physicians with Medicare fee-for-service patients do not need to be contracted with Medi-Cal managed care plans to continue to see their dual-eligible patients. However, these patients will need to opt out of Cal MediConnect to continue receiving services under original fee-for-service Medicare. Again, if a patient opts out of Cal MediConnect, they will be still required to join Medi-Cal Managed Care plan in order to receive their Medi-Cal health benefits.

Patients who don’t opt out and are enrolled in a Cal MediConnect plan will generally need to receive their care from physicians who contract with their Cal MediConnect plan.

For more information on participating with a Cal MediConnect plan, visit www.calduals.org/wp-content/uploads/2014/09/PhysToolkit_Contracting-with-Cal-MediConnect-Plans_09.17.14.pdf.

Finally, even if a patient is enrolled in a Cal MediConnect plan with which the physician does not contract, the patient has the option to opt out or change plans at any time. Decisions to opt out are effective the next month.

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QUESTION 6: If my patient selects a plan in which I am not contracted, can I continue to see the patient?

If your patient elects a Cal MediConnect plan for their Medicare and Medi-Cal benefits with which you are not contracted, you may be able to continue to see the patient for a limited period of time, under the continuity of care rules.

Under the Cal MediConnect continuity of care rules, once patients are enrolled in a Medi-Cal managed care plan, they can continue to see a physician with whom they have an existing relationship, even if the physician is not contracted with the plan, for up to six months for Medicare and up to 12 months for Medi-Cal services if certain criteria are met:

Medicare Services:

• Patient demonstrates they have seen the out-of-network physician at least twice in the previous 12 months
• Physician must be willing to accept payment from the plan at Medicare rates
• The plan would not have otherwise excluded that physician from its network due to quality or other concerns

Medi-Cal Services (1):

• Patient demonstrates they have seen the out-of-network physician at least twice in the previous 12 months
• Physician must be willing to accept payment from the plan based on the plan’s reimbursement rate or Medi-Cal rate (whichever is higher)
• The plan would not have otherwise excluded that physician from its network due to quality or other concerns

A pre-existing relationship with the out-of-network physician may be established by the plan using Medicare data or by documentation from the provider or enrollee.

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QUESTION 7: Can I request continuity of care on behalf of my patients?

DHCS implemented new continuity of care rules in September that make it easier for patients to continue receiving needed care from out-of-network physicians without interruption. The new rules state:

1. Providers can request continuity of care for their patients under the duals demonstration project. Previously, only the patient could initiate such a request. This new rule will help beneficiaries who have difficulty navigating the healthcare system so they can maintain their provider for up to 12 months.
2. Continuity of care requests can be made via telephone, and plans will be prohibited from requiring beneficiaries to submit a request through a paper form.
3. Continuity of care requests must be processed within three days if there is a risk of harm to the beneficiary. Urgent requests will be processed within 15 days, and all other requests are to be processed within 30 days.
4. Providers or the beneficiary can now request continuity of care after the service has been delivered — ensuring payment for treatment. To qualify, the request must be received within 20 business days of the first service following the beneficiaries’ enrollment in Cal MediConnect. Once a beneficiary is approved for continuity of care, providers must work with the health plans to ensure compliance with the plan’s utilization and management policies.

These changes in continuity of care do not apply to providers of DME, transportation or ancillary services.

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QUESTION 8: Who do I bill and what are the reimbursement rates?

For patients who opt to keep their fee-for-service Medicare coverage, physicians will continue to bill fee-for-service Medicare as they have in the past. There is no change in what fee-for-service Medicare will pay, which is generally 80% of the Medicare allowed amount. It should be noted that no change has been made to the rules governing the billing of the 20% Medicare copay for dual-eligible patients. It continues to be unlawful to bill dual-eligible patients. In limited circumstances, Medi-Cal may cover Medicare coinsurance and copays. Such “crossover” claims for Medicare coinsurance and copays should be sent to the patient’s Medi-Cal plan (see Payment for Medicare Physician Services Under the CCI fact sheet for more information).

Patients who do not opt out and are enrolled in a Cal MediConnect plan for their Medicare and Medi-Cal benefits generally need to receive their care from physicians who participate in the Cal MediConnect plan network. The exception to this rule is if continuity of care is approved (see previous question for a discussion of the Cal MediConnect continuity of care rules).

Physicians who participate in the patient’s Cal MediConnect plan will seek payment directly from that managed care plan or whomever the plan delegates to (i.e., IPA or medical group) and will be reimbursed based on the terms of their contracts.

For more information on rates and payment rules, please see the CalDuals “Payment for Medicare Physician Services” fact sheet.

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QUESTION 9: If my patient opts out and remains with the fee-for-service Medicare, will the crossover claim automatically forward to the Medi-Cal managed care plan?

Probably not. According to the CalDuals website, “Most Medi-Cal plans are not yet participating in this automated process.” For a list of which plans receive crossover claims automatically and for more information, see the CalDuals fact sheet, “How Physician Crossover Claims are Processed for Beneficiaries in Medi-Cal Managed Care Plans.” If the patient’s plan is not yet participating in the automated crossover claim process, the practice will need to submit a claim to the crossover plan in order to be paid any amount due.

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QUESTION 10: If my patient opts out and remains with fee-for-service Medicare, do I need to be contracted with the patient’s Medi-Cal managed care plan to receive deductible and coinsurance payments?

No. According to the CalDuals website, physicians do not need to be part of the Medi-Cal plan’s network to have crossover claims processed and paid. For more information, see the CalDuals fact sheet “Providing Fee-for-Service Medicare Services to Dual-Eligibles in Medi-Cal Plans.”

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QUESTION 11: If my patient opts out and remains with fee-for-service Medicare, can the Medi-Cal managed care plan require an authorization?

No. The CalDuals website confirms that if a patient opts out and remains with fee-for-service Medicare, the Medi-Cal managed care plan cannot require authorizations for physician services as the secondary payor (see the CalDuals “Overview of the Coordinated Care Initiative” fact sheet).

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QUESTION 12: How do I identify a Cal MediConnect patient versus regular Medi-Cal managed care patient?

Prior to delivering services, you or your staff will determine eligibility in the AEVS system. The AEVS eligibility information will contain the name of the patient’s plan. The Cal MediConnect plans will each have a unique name as compared with the standard Medi-Cal managed care plans. Practices are encouraged to familiarize themselves with the Cal MediConnect plans in their county (below).

County (2)	Cal MediConnect Plan Name	Medi-Cal Managed Care Plan Name
Alameda	Alameda Alliance Complete Care	Alameda Alliance
	Anthem Blue Cross	Anthem Blue Cross
		Kaiser Permanente
Los Angeles	Health Net Cal MediConnect	Health Net
	Molina Dual Options	Molina Health Plan
	L.A. Care	L.A. Care
	CareMore	Anthem Blue Cross
	Care 1st Cal Mediconnect Plan	Care 1st Health Plan
		Kaiser Permanente
Riverside & San Bernardino	IEHP Dual Choice	Inland Empire Health Plan
	Molina Dual Options	Molina Health Plan
		Kaiser Permanente
		Health Net
San Diego	Care 1st Cal MediConnect Plan	Care 1st Health Plan
	Health Net Cal MediConnect	Community Health Group
	CommuniCare Advantage	Health Net
	Molina Dual Options	Molina Health Plan
		Kaiser Permanente
Santa Clara	Santa Clara Family Health Plan Cal MediConnect	Santa Clara Family Health Plan
	Anthem Blue Cross	Anthem Blue Cross
		Kaiser Permanente