Complex health care system for California’s elderly and poor explained

SANTA CLARA, California – Now that about eight million have enrolled in health care plans under the Affordable Care Act (ACA or Obamacare), what happens to those who do have Medicare, Medicaid, Medi-Cal, Kaiser, other health care plans or combinations of plans?

Sourcewise (formerly Council on Aging Silicon Valley) recently invited the public to its third session in explaining the Coordinated Care Initiative (CCI), a somewhat confusing and involved process. Sourcewise has made it easier for close to 2,000 attendees to understand CCI.

California took the lead in implementing a health care program that may soon become the nationwide model depending on its progress in the selected eight counties.

California’s CCI passed in July 2012. This year, the goal is to fully implement it in Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara Counties

In Santa Clara County, residents with Medi-Cal number about 210,000. Residents with both Medicare and Medi-Cal are about 35,000. No estimate was given on residents with Kaiser or other work-related health care plans.

“Approximately 5,700 Asian seniors live in poverty (in the county),” said Marcelo Espiritu, Sourcewise Health Insurance product analyst. ‘Seventy-six percent of Asian seniors struggle to meet basic needs. About 15 percent of the 77,000 Asian seniors are Filipino in Santa Clara.”

Medicare beneficiaries possess the white card with red and blue stripes on top. They are 65 years or older or under 65 with certain disabilities such as End-Stage Renal Disease (ESRD).

Medi-Cal beneficiaries possess the plain white card with the state’s seal on the front. They are usually low-income Californians.

What CCI offers

Basically, CCI offers:

• mandatory enrollment of 21 or older Medi-Cal beneficiaries and Medi-Cal with Medicare beneficiaries (or Dual Eligibles) into managed care that includes Long-term Services and Supports (LTSS);

• optional enrollment into an integrated managed care that combines Medicare and Medi-Cal benefits known as the Cal MediConnect program.

This will virtually make LTSS available to all. It includes

• In-home Support Services (or IHSS – a personal care service for people who need help to live safely in their homes);

• Community-based Adult Services (or CBAS – a daytime health care center that provides nursing, therapy, activities and meals for people with certain chronic health conditions);

• Multi-purpose Senior Services Program (or MSSP – provides social and health care management for people age 65 and over);

• Nursing home care (to provide better coordinated care for those already in a nursing home).

Aside from the regular Medicare and Medi-Cal services, Cal MediConnect will provide just one phone number to call for all health care needs, one routine eye exam yearly and a $100 co-pay for eyeglasses/contacts every two years, 30 one-way non-emergency trips per year in addition to the existing transportation benefit and care coordination.

Care coordination – perhaps, the most touted feature of Cal MediConnect — makes health care more patient-centric with features like

• Health Risk Assessments (or HRAs that determine if the beneficiary needs primary or acute care, LTSS and requires behavioral health and functional needs);

• Interdisciplinary Care Teams (or ICT);

• Individualized Care Plans (that will develop and implement ICTs);

• Plan Care Coordinators (that facilitate the communication between plans, providers and the beneficiary).

But part of the initial obstacle that makes CCI seem overwhelming is the different situations beneficiaries find themselves in with regard to their different health care plans or combination of plans. The transition from old plan to new depends on their current plan and their eligibility for Cal MediConnect.

Likely scenarios

According to data collected and tabulated by Santa Clara Family Health Plan, the following are the six likely scenarios for those who are in Medicare, Medicare and Medi-Cal, Kaiser and other health care plans, facing the transition into the integrated management of healthcare:

• Those enrolled in a Medi-Cal managed care health plan like Anthem Blue Cross or Santa Clara Family Health Plan will get notice from the California Department of Health Services (CDHS) of the expansion of their benefits to include LTSS by May. Their expanded benefits will be managed by the new plan on July 1. If also enrolled in MSSP, it begins on August 1. Those in On Lok Lifeways or PACE, won’t get notice because they already have LTSS.

• Those in regular Medi-Cal but not enrolled in a Medi-Cal managed care health plan will get 90-, 60- and 30-day notices from CDHS to choose a managed care health plan beginning May. They need to choose a Medi-Cal managed care health plan beginning August 1. They can opt for PACE if they qualify. If they don’t choose a Medi-Cal managed plan, the state will select for them.

• Those enrolled in a Medi-Cal managed care health plan with Medicare like Anthem Blue Cross or Santa Clara Family Health Plan and do not qualify for Cal MediConnect (because they don’t have full Medicare and full Medi-Cal or have ESRD or are in Kaiser or in a 1915c waiver [an option for long term care set in a home or community]), will get notice of the expansion of their benefits to include LTSS in May. In July 1, their benefits will be managed by the new plan. If they have MSSP, it begins in August 1.

• Those with Medicare and regular Medi-Cal but are not enrolled in a Medi-Cal managed plan (and do not qualify for Cal MediConnect because they don’t have full Medicare and full Medi-Cal or have ESRD or are in Kaiser or in 1915c waiver) will get 90-, 60- and 30-day notices from CDHS with instructions to choose a Medi-Cal managed plan beginning May. Their new plan starts August 1. They can also choose PACE if eligible. Beneficiaries born in July and August will be enrolled at the same time. If they don’t select a Medi-Cal managed plan, the state will select for them.

• For those in Medicare and in a Medi-Cal managed plan like Anthem Blue Cross or Santa Clara Family Health plan and qualified for Cal MediConnect, a notice about the expansion of benefits to include LTSS will come in May. In July 1 their expanded benefits will be managed by the new plan. If they have MSSP, it begins August 1. In October, November, December 90-, 60- and 30-day notices from CDHS will inform them of their options. In January 1, 2015, they can enroll in a Cal MediConnect plan for both Medicare and Medi-Cal benefits. They can opt out of Cal MediConnect by staying with their regular Medicare but continue to be enrolled in their Medi-Cal managed plan. They also can choose PACE for both Medicare and Medi-Cal benefits, if eligible. If they don’t choose, the state will select a Cal MediConnect plan for them.

• Those with Medicare and regular Medi-Cal but are not enrolled in a Medi-Cal managed plan and are eligible for Cal MediConnect will get 90-, 60- and 30-day notices from CDHS about their options. In January 1, 2015, they can enroll in a Cal MediConnect plan for both Medicare and Medi-Cal benefits. They can also opt out of Cal MediConnect and stay with their Medicare but choose a Medi-Cal managed plan for their Medi-Cal benefits. Or they can choose PACE for both Medicare and Medi-Cal benefits, if qualified. If they don’t choose, the state will select a Cal MediConnect plan for them.

Not bug-free

The process is still a long way from bug-free. Some doctors reportedly turn away former Medicare patients mistakenly believing they now only have Medi-Cal.

The new system requires doctors to bill Medicare first and then bill Medi-Cal for 20 percent. The Medicare doctor doesn’t need to be a part of the Medi-Cal network to get paid the 20 percent.

Also, the current system has plans that don’t seamlessly coordinate with the others. Staff Attorney Amber Cutler of the National Senior Citizens Law Center advises that the best match for those in Kaiser (on the Medicare side) is the Santa Clara Family Health Plan (on the Medi-Cal side). Those with Caremore (on the Medicare side) match with Anthem Blue Cross (on the Medi-Cal side).

Espiritu said, “There are 10,994 Filipinos on Medi-Cal, based on the county social service report for January 2014. Most of them are already in a Medi-Cal Plan, but some will still need to sign up for Medi-Cal. I would estimate that of those 10,994, over 1,200 Dual Eligible Filipinos who are eligible for Cal MediConnect.”

He continued: “There are 37,684 Vietnamese and 11, 877 Chinese in our County. Over 8,100 dual eligible Vietnamese and over 2,800 dual eligible Mandarin speakers qualify for Cal MediConnect.”

Espiritu also said, “There is no cost for the Cal MediConnect Plan. But beneficiaries have to use providers or suppliers in their plan network to ensure that the service, durable medical equipment, supply or drug is covered by the Plan.”

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