1. Cal MediConnect Martha Smith
Chief Program Officer, Dual Eligible Demonstration
Health Net, Inc.
Paul Van Duine
Senior Director of Provider Network Operations
L.A. Care Health Plan
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CAPG Southern California Contracts Committee Meeting
Annual joint meeting with HASC
October 3, 2013 1

2. Agenda
Background and General Update LA Care Network Strategy Coordinating Behavioral Health Health Net Network Strategy

3. California is implementing a Duals Demonstration under the Coordinated Care Initiative
The passing of the Coordinated Care Initiative (CCI) is a catalyst for three key changes in California healthcare in the 8 selected counties:
Mandatory enrollment into a Medi-Cal health plan
California CCI Legislation
Mandatory transition of Medi-Cal Long Term Services and Supports (LTSS) to Medi-Cal health plans
Basic Background
The passage of the Coordinated Care Initiative (CCI) in 2012 transforms California's Medi-Cal (Medicaid) care delivery system by beginning the process of integrating delivery of medical, behavioral, and long-term care services. It provides a road map to integrate Medicare and Medi-Cal for people in both programs, called “dual eligible” beneficiaries. The CCI was enacted through SB 1008 (Chapter 33, Statues of 2012) and SB 1036 (Chapter 45, Statues of 2012).
Coordinated Care Initiative
Cal MediConnect:
A voluntary three-year demonstration program for Medicare and Medi-Cal dual eligible beneficiaries will coordinate medical, behavioral health, long-term institutional, and home-and community-based services through a single health plan. The CCI provides state authority for Cal MediConnect. The MOU executed in March 2013 with the federal Centers for Medicare & Medicaid Services (CMS) provides federal approval.
Managed Medi-Cal Long-Term Supports and Services (LTSS):
Nearly all Medi-Cal beneficiaries age 21 and older, including dual eligible beneficiaries, will be required to join a Medi-Cal managed care health plan to receive their Medi-Cal benefits, including LTSS and Medicare wrap-around benefits.
Most Medi-Cal beneficiaries will have to join a Medi-Cal health plan for benefits like:
LTSS (see following slides)
Non-emergency transportation (medically necessary)
Incontinence supplies
Some medical equipment that Medicare doesn’t cover.
Dually Eligible beneficiaries can join the Duals Demonstration and get ALL of their healthcare from one health plan (Medicare and Medi-Cal benefits).
Dually Eligible beneficiaries can opt out of joining a health plan for the Medicare portion of their services. They will have to remain in a health plan for their Medi-Cal services.
Voluntary transition of Dual Eligibles into a Demonstration plan (passive, with opt-out)

4. As a result of CCI, what changes for Medi-Cal Benes?
Most Medi-Cal beneficiaries will have to join a Medi-Cal health plan for benefits like:
Long Term Services and Supports (LTSS)
Non-emergency transportation (medically necessary)
Incontinence supplies
Some medical equipment that Medicare doesn’t cover.
Dually Eligible beneficiaries can join the Duals Demonstration and get ALL of their healthcare from one health plan (Medicare and Medi-Cal benefits)
Dually Eligible beneficiaries can opt out of joining a health plan for the Medicare portion of their services. They will have to remain in a health plan for their Medi-Cal services

5. California Demonstration Sites
Eight counties have been selected based on current State authority*:
Los Angeles (DE pop. 374 K, eligible: 271K)
Health Net
LA Care
San Diego (DE pop. 75 K eligible: 51K)
Molina
Care 1st
Community Health Group
Orange (DE pop. 73 K eligible: 57K):
CalOptima
San Bernardino (DE Pop. 54 K eligible: 36K)
Inland Empire Health Plan
Molina Healthcare
Riverside (DE Pop. 50 K eligible: 34K)
Santa Clara (DE Pop. 50 K eligible: 35K)
Anthem Blue Cross
Santa Clara Family Health Plan
Alameda (DE Pop. 42 K eligible: 31K)
Alameda Alliance for Health
San Mateo (DE pop. 15 K eligible: 11K)
Health Plan of San Mateo
Slide duals in LA, Slide K. Stay with 374K.
Remove double page numbers on all

6. What will the Program Look Like? Benefit Plan Configuration
Medicare:
Parts A, B, and D benefits covered
Medi-Cal:
All Medi-Cal services currently required in managed care services
Long-Term Supports and Services
Skilled Nursing
Home and Community-Based programs
Supplemental benefits:
Vision, Transportation
(optional dental)
Coordination:
With mental health and substance use programs
Other “non-benefit” community based programs

7. What will the Program Look Like? Who and How?
Who Will Be Included in Cal MediConnect?
Beneficiaries eligible for both full benefit Medicare and Medi-Cal in the CCI counties
Populations excluded from the Demo
Partial-Benefit Dual Eligibles
Beneficiaries with other health coverage (not including Medicare Advantage or partial coverage plans)
Beneficiaries under age 21
Existing ESRDs (enrollment will be consistent with MA today)
Beneficiaries with developmental disabilities receiving services through Regional Centers or a State Developmental Center
Enrollees of selected waiver programs
Beneficiaries living in zip codes not covered by managed care

8. What will the Program Look Like? Timing
The Demonstration will begin no sooner than April 1, 2014
Enrollment
Enrollment for the eight counties in the CCI will have different approaches
Los Angeles  enrollment will phase in over 12 months with the first three months being a period of only active choice enrollment
Active/elective enrollment April – June 2014
Passive enrollment by birth month beginning July 2014 – March 2015
200,000 enrollment cap
San Diego  enrollment will phase in over 12 months by birth month beginning April 2014
San Mateo and Orange  commence all at once on April 2014
Passive enrollment with a voluntary opt out for the Medicare benefit only
Beneficiaries can opt out of Cal MediConnect
If beneficiaries don’t choose to opt out or select a health plan, they will be automatically enrolled by the State into either L.A. Care or Health Net
Current D-SNP and MA enrollees are passively enrolled in January 2014
Beneficiaries can still opt out later even if they get automatically enrolled
Financing:
Capitated payment models with 3-way contracts between CMS, CA Department of Health Care Services (DHCS), and health plans

9. Coordinated Care Initiative Requirements
The legislation establishing the CCI contains many projections for beneficiaries covering:
Meaningful Information of Beneficiary Rights and Choices:
Notices sent at least 90, 60, and 30 days prior to enrollment (coordinated with CMS)
Continuity of Care
People can continue to see their Medi-Cal providers for 12 months and Medicare doctors for 6 months
Self-Directed Care:
People will have the choice to self-direct their care, including being able to hire, fire, and manage their IHSS workers
Appeals & Grievances:
DHCS is working with CMS on a coordinated appeals process
Strong Oversight & Monitoring:
Evaluation Coordinated with DHCS and CMS