Mandatory Medi-Cal Managed Care Enrollment for Special Populations

Mandatory Medi-Cal Managed Care Enrollment for Special Populations

Seniors and Persons with Disabilities (SPD) in the past have not been required to enroll in Medi-Cal Managed Care, or a Medi-Cal health plan. That is changing. Many are now required to enroll in a Medi-Cal health plan. This change is being implemented in 14 counties including Los Angeles.

 

The following SPDs are exempt from mandatory enrollment:

  • beneficiaries with Medi-Cal and either Part A and Part B Medicare,
  • beneficiaries who are enrolled in a community based waiver program,
  • children who are enrolled in CCS and have a disability-based Medi-Cal aid code,
  • and children who receive foster care or adoption assistance benefits.

 

Process for mandatory enrollment

 

Mandatory enrollment depends on the SPD’s birth month. Enrollment has begun for people with birthdays in May and will continue each month through May of 2012.

 

  • Beneficiaries will receive a letter from Health Care Options 90 days before their birth month.
  • They will receive an enrollment packet and phone calls 60 days before their birth month.
  • Non-exempt beneficiaries must choose a health plan by the 20th day of their birth month.

 

IMPORTANT: A dental choice form is included in the enrollment packet so it’s important that clients  know that enrolling into a dental managed care plan is still optional and they are not required to sign up for a dental plan.

 

Beneficiaries should talk to their providers to try and be sure they choose a plan that includes their provider, their specialists, if any, and the hospital they prefer, although it may not always be possible to include all these providers in the plan they choose. If the beneficiary does not respond there will be a “soft default”. This means that Health Care Options will attempt to default them into a plan that contracts with their provider. If the beneficiary’s provider does not participate in a managed care plan, the beneficiary is supposed to be able to continue to see his or her provider for up to a year. The provider should be reimbursed by the health plan.

 

However, the ability to continue after that year depends on whether the provider will accept a contract from the managed care plan. The plan must offer a contract. There are no instructions yet as to how the beneficiary requests that their doctor accept a managed care contract. If the doctor will not, or is still negotiating with the plans by the time the beneficiary must choose a health plan, the beneficiary could request an medical exemption to stay on Fee for Service Medi-Cal. We are still not sure how the interplay between the request to contract with the provider and the medical exemption request will work. Please keep in touch with your examples and questions and we will send out clarification when we have it. 

If an SPD is already in a managed care plan:

SPD beneficiaries voluntarily in a managed care plan will get a letter in May informing them that as of June 1 they are no longer voluntary managed care, but now mandatory managed care. They will not receive an enrollment packet.

As of July, 2011, any SPD beneficiary enrolling in Medi-Cal will be a mandatory managed care enrollee, unless they are in an exempt category or request a medical exemption.

 

To enroll in a plan contact Health Care Options: 1-800-430-4263

 

For more information visit the state website

 

For problems or questions contact:

The Health Consumer Center 1-800-896-3203 or

Maternal and Child Health Access 1-213-749-4261

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