While close to 70% of Medicare beneficiaries with Medi-Cal (also known as dually eligible beneficiaries) receive their Medi-Cal benefits through a Medi-Cal managed care plan, in 2023 that number will increase to close to 100%. This increase is a result of the Department of Health Care Services’ (DHCS) multi-year project, CalAIM (California Advancing and Innovating Medi-Cal). It is being implemented in the years 2022-2027.
One of CalAIM’s many goals is to provide “standard enrollment with consistent managed care benefits”. Hence it is implementing mandatory enrollment into Medi-Cal managed care plans for all dually eligible beneficiaries as of January 1, 2023. This is happening statewide, though primarily in counties that don’t currently require dual eligibles to enroll in Medi-Cal managed care plans, and will affect approximately 325,000 beneficiaries. These counties are: Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, El Dorado, Fresno, Glenn, Imperial, Inyo, Kern, Kings, Madera, Mariposa, Mono, Nevada, Placer, Plumas, Sacramento, San Benito, San Francisco, San Joaquin, Sierra, Stanislaus, Sutter, Tehama, Toulomne, Tulare, and Yuba.
This change is for all people on Medicare and Medi-Cal, those dually eligible with other health coverage, 1915c Home and Community Based Services waiver enrollees, and dually eligible beneficiaries in skilled nursing facilities (SNFs). It does not affect dually eligible individuals who have a share of cost living in the community (versus a SNF), those enrolled in a SCAN health plan, Program of All Inclusive Care for the Elderly (PACE) enrollees, residents of California veteran homes, and Native Americans who chose fee-for-service Medi-Cal.
Notices regarding the change will be mailed 60 and 30 days prior to the change, starting in early November. Medi-Cal managed care plans are also allowed to start calling affected beneficiaries in December.
What does this change mean?
Medicare will remain primary, Medi-Cal coverage will continue to be secondary, and Medicare provider relationships will remain the same. Medicare providers do not have to have a contract with the Medi-Cal plan in order to bill. They can bill the Medi-Cal plan for non-Medicare covered services, such as:
- Long term services and supports (community-based services, long term nursing facility care)
- Community supports
- Enhanced care management
- Transportation to and from medical appointments
Dually eligible beneficiaries continue to be protected from improper balance billing. This occurs when Medicare providers seek to bill a beneficiary for Medicare cost sharing, which includes deductibles, coinsurance, and copayments. The provider can always submit a bill to the Medi-Cal plan, and as mentioned, does not need to be contracted with the Medi-Cal plan to do so. But s/he cannot bill a dually eligible beneficiary for these costs. It’s illegal. Dually eligible beneficiaries are not financially responsible for services covered under Medicare or Medi-Cal (except if on Share of Cost Medi-Cal or for Part D prescription co-payments).
Dually eligible beneficiaries can also continue to chose their Medicare primary care provider (PCP) as they have been; the Medi-Cal plan can’t require someone to chose a PCP from their plan.
In addition, dually eligible beneficiaries who are on fee-for-service Medi-Cal receiving Medi-Cal-covered long-term care services in a skilled nursing facility (SNF), intermediate care facility (ICF) or sub-acute facility, will be required to enroll in a Medi-Cal managed care plan as of January 1, 2023. Medi-Cal managed care plans will be responsible for paying these long term care services benefits.
For more information on these changes, listen to our partners at Justice in Aging’s recent webinar: Upcoming Changes to Medi-Cal in 2023.
