Mandatory Enrollment of Seniors and Persons with Disabilities in Medi-Cal Managed Care

The following was pubished in a Newsletter by Disability Rights California -- www.disabilityrightsca.org and from the World Institute on Disability www.wid.org

It gives a great overview of the mandated enrollment of some of California's Medi-Cal recipients into a managed care program.

Q: I receive Medi-Cal. Will I have to enroll in managed care?
A: Many seniors and persons with disabilities, approximately 380,000 people, will have to join a Medi-Cal managed care plan if they live in one of the 14 counties on the list below:

Alameda
San Bernardino
Contra Costa
San Diego
Fresno
San Francisco
Kern
San Joaquin
Los Angeles
Santa Clara
Riverside
Stanislaus
Sacramento
Tulare

But not everyone in these counties will be affected. You do not have to enroll in a managed care plan if:

1. You have Medicare as well as Medi-Cal
2. You receive services from the California Children’s Services (CCS) program, or
3. You receive foster care or adoption assistance benefits


Q: When will these changes take effect?
A: Mandatory enrollment will depend on your birth month. Mandatory enrollment will begin in June 2011 for people with birthdays in June; it will begin in July for people with birthdays in July, and so forth. This process will continue for one year, through May 2012.

Q: What is managed care?
A: Managed care means that you receive your health care from a managed care plan. A managed care plan is an organized network of health care providers, which emphasizes primary and preventive care. Hospitals, physicians and other health care providers are members of the network. The managed care plan can be public or private.

Q: Are there any benefits to managed care?
A: Yes. Managed care plans can provide you with the following:

• Help coordinating your care
• Help finding primary care doctors and specialists
• Help finding a pharmacy
• Ongoing referrals to specialists
• Telephone advice nurses
• Customer service centers
• Support groups
• Health education programs to:
• Quit smoking
• Prevent and deal with drug and alcohol problems
• Manage chronic pain
• Eat well and exercise safely
• Help getting to and from medical appointments (non-medical transportation)


Q: If I’m in managed care, can I keep the same doctors I have now?

A: Ordinarily, your doctor must be part of the managed care network. However, if you now have a doctor who is not part of the managed care network, you can keep that doctor; but only if the doctor is both willing to keep seeing you and willing to accept the managed care network’s payment rate or the Medi-Cal fee-for-service rate, whichever is higher. The doctor becomes a part of the managed care network just for purposes of caring for you. The doctor will have access to network providers for purposes of referrals, etc.

Q: If I don't already have doctors I like, will the health plan provide ones who know about my disability?

A: The Medi-Cal managed care plan can help you find a doctor's office that will meet your special needs. Your doctor and the health plan will be responsible for helping to coordinate your care. This includes helping you find the specialists you need. In addition, the managed care plan has telephone advice nurses to answer your health questions and customer service call centers to answer questions about your benefits.

Q: What if I don't like managed care – can I get out?

A: No. However, if you have a “complex medical condition” the managed care plan must provide continuous care with your current provider for up to one year after you enroll in the managed care plan. This is true whether or not the provider is willing to accept the managed care network’s payment rate. The state is finalizing requirements for this “exceptions process.”

Q: I live in a rural county without any Medi-Cal managed care plans. Will I have to enroll in a managed care plan?

A: No.

Q: How will I know what to do to enroll?

A: You should be getting letters and phone calls beginning about 90 days before you are required to enroll. The letters and phone calls will explain the steps you need to take and the options for managed care providers in your area.

Q: I don’t have to enroll in managed care but I want to. Is it possible for me to enroll voluntarily?

Yes, as long as your county has at least one managed care network that accepts Medi-Cal.

Q: How can I find out more about the managed care plans in my area and pick the best one for me?

A: You can find information about Medi-Cal managed care on the Health Care Options (California Department of Health Care Services) website: http://www.healthcareoptions.dhcs.ca.gov/HCOCSP/Home/. You can also call Health Care Options at: 1-800-430-4263. There are also contact numbers for languages other than English. Here is the list:

Health Options
(California Department of Health Care Services)
Contact Numbers




Employment Matters Editor
Josephine Schallehn
World Institute on Disability
josephine@wid.org