1. C ALIFORNIA ’ S C OORDINATED C ARE I NITIATIVE : M ANDATORY M EDI -C AL M ANAGED C ARE E NROLLMENT AND THE D UAL D EMONSTRATION P ROJECT Presented by the Center for Health Care Rights September 2012

2. C ALIFORNIA ’ S COORDINATED CARE INITIATIVE In July 2012, the California Coordinated Care Initiative was passed into law by the California Legislature. The CCI has two key components: 1) Managed Medi-Cal Long Term Care Supports and Services All Medi-Cal beneficiaries, including dual eligibles will be required to join a Medi-Cal managed care plan to receive their Medi-Cal benefits (including LTSS and Medicare wraparound benefits). 2 Copyright (c) September 2012 by Center for Health Care Rights

3. All Medi-Cal LTSS benefits include: In Home Supportive Services Multipurpose Senior Centers (MSSP); CBAS; Nursing facilities. 2)Dual Demonstration Project: A voluntary three year demonstration program for Medicare/Medi-Cal dual eligibles will coordinate all medical, behavioral health, long term institutional and home and community based services through an integrated care model. 3 Copyright (c) September 2012 by Center for Health Care Rights

4. C ALIFORNIA ’ S D UAL E LIGIBLE D EMONSTRATION P ROJECT On May 31, 2012, California submitted its proposal regarding the Dual Demonstration project to the Centers for Medicare & Medicaid Services (CMS) for federal approval. CMS is expected to respond to California’s proposal by the end of October 2012. California’s proposal, along with other documents related to the Demonstration, can be viewed at www.calduals.org. www.calduals.org 4 Copyright (c) September 2012 by Center for Health Care Rights

5. C OORDINATED C ARE I NITIATIVE DHCS will need federal approval to require all Medi-Cal beneficiaries to join Medi-Cal managed care plans in order to retain their Medi-Cal benefits. 5 Copyright (c) September 2012 by Center for Health Care Rights

6. I MPLEMENTATION T IMEFRAME FOR CCI Subject to CMS approval, implementation of the CCI will occur at the earliest March 1, 2013 and the latest June 1, 2013. 6 Copyright (c) September 2012 by Center for Health Care Rights

7. D UAL D EMONSTRATION E NROLLMENT P ROCESS Enrollment is voluntary and will occur through a passive enrollment process. Duals in demonstration counties who do not opt out will be passively enrolled into a Demonstration Plan. DHCS will use Medicare and Medi-Cal claim data to help identify a Demonstration plan for the dual eligible. If the dual has seen a provider who participates in one of the plans, s/he will be enrolled into that plan. Enrollment will likely be phased in based on beneficiary’s birthday month. 7 Copyright (c) September 2012 by Center for Health Care Rights

8. W HO I S E LIGIBLE FOR THE D UAL D EMONSTRATION ? Live in one of the 8 Demonstration Counties (Los Angeles is included) Be age 21 or older Have full Medi-Cal and Medicare A & B Have Medi-Cal with a Share of Cost (SOC) that they meet every month through Medi-Cal LTC, IHSS, MSSP 8 Copyright (c) September 2012 by Center for Health Care Rights

9. D UAL E LIGIBLE B ENEFICIARIES E XCLUDED F ROM T HE D EMONSTRATION  Beneficiaries with other insurance  Persons with ESRD  Developmentally disabled persons – receiving services through a Regional Center and ICF-DD residents  Beneficiaries enrolled in a 1915© waiver programs e.g. HIV/AIDS waiver services  Beneficiaries living in a VA nursing homes in California 9 Copyright (c) September 2012 by Center for Health Care Rights

10. D UAL E LIGIBLES E XEMPT F ROM P ASSIVE E NROLLMENT I NTO THE D UALS D EMONSTRATION Beneficiaries enrolled into PACE or AIDS Healthcare Foundation Beneficiaries enrolled into a Medicare Advantage plan (delayed enrollment to 2014). 10 Copyright (c) September 2012 by Center for Health Care Rights

11. CCI M ANDATORY M EDI -C AL M ANAGED C ARE E NROLLMENT – E XCLUDED P OPULATIONS All Medi-Cal beneficiaries in the 8 demonstration counties will be required to enroll into a Medi-Cal managed care plan except for the following groups: Beneficiaries under the age of 21; Beneficiaries living in ICF/DD facilities; Beneficiaries living in a VA nursing facilities; Beneficiaries enrolled in PACE and AIDS Healthcare Foundation; Beneficiaries with other health insurance; Beneficiaries approved for Medical Exemption Request. 11 Copyright (c) September 2012 by Center for Health Care Rights

12. CCI M ANDATORY M EDI -C AL M ANAGED C ARE E NROLLMENT – P OPULATIONS THAT ARE E XEMPT OR THAT C AN O PT O UT Medicare Advantage HMO and SNP enrollees are exempt from passive enrollment into Medi-Cal managed care plan during 2013. American Indian beneficiaries – will be passively enrolled but can opt out on a monthly basis. Beneficiaries with HIV/AIDS – will be passively enrolled but can opt out on a monthly basis. 12 Copyright (c) September 2012 by Center for Health Care Rights

13. N OTIFICATION Will start 90 days prior to enrollment. Similar to the SPD notification process, this notification process will include three notices and an enrollment packet sent out to duals in Demonstration counties. The State intends to use Health Care Options as the enrollment broker for both the Medicare and Medi-Cal components of the Demonstration. 13 Copyright (c) September 2012 by Center for Health Care Rights

14. O UTREACH DHCS wants to involve a variety of stakeholder groups including advocacy organizations, community based organizations, Independent Living Centers, HICAPs, etc. to help with the outreach. The Proposal speaks specifically to the key role HICAPs will play in helping duals understand their options. 14 Copyright (c) September 2012 by Center for Health Care Rights

15. M EDI -C AL B ENEFITS IN D EMONSTRATION C OUNTIES All Medi-Cal benefits will be provided by the Demonstration plans. This includes all Medi-Cal long term care services, including IHSS and Medi-Cal nursing home care. IHSS will remain an entitlement program. Counties will continue to determine IHSS hours and services. IHSS consumers will be able to hire, fire and manage their IHSS workers. The current fair hearing process for IHSS will remain available during 2013. 15 Copyright (c) September 2012 by Center for Health Care Rights

16. MSSP (case management) services will continue to be provided by MSSP providers that contract with Demonstration plans. Mental health services: Demonstration health plans will provide all mental health and substance use services covered by Medicare and Medi-Cal. However, county administered specialty health services and Drug Medi-Cal substance use treatment services will be carved out of the plans’ capitation payments. Health plans and county agencies will have written agreements regarding coordination of services. 16 Copyright (c) September 2012 by Center for Health Care Rights

17. C ONTINUITY OF C ARE The Dual Demonstration Proposal states that dual eligible enrollees will have access to out of network providers for a period of time under a continuity of care policy. They will have access to out of network providers for six months for Medicare benefits and 12 months for Medi-Cal benefits. Other than the timeframe outlined above, the Continuity of Care policy has the same features and requirements that apply to the SPD population. 17 Copyright (c) September 2012 by Center for Health Care Rights

18. A PPEALS AND G RIEVANCES For the first year of the Demonstration, the State proposes that existing Medicare and Medi-Cal appeals/grievance systems will be available for Demonstration participants. DHCS will work with CMS and seek stakeholder input into the design of a single appeals/grievance process to be implemented in future years. 18 Copyright (c) September 2012 by Center for Health Care Rights

19. D UAL D EMONSTRATION IN L OS A NGELES C OUNTY Los Angeles County will be one of the Demonstration counties. The 2 plans that have been selected for the Los Angeles Demonstration are L.A. Care and Health Net. Both Los Angeles plans have a Medicare Advantage dual SNP plan and a Medi-Cal HMO plan. 19 Copyright (c) September 2012 by Center for Health Care Rights