Why is Medi-Cal coverage changing?
California’s proposal to restructure Medi-Cal was approved by the Centers for Medicaid and Medicare Services (CMS), the federal agency that oversees Medicaid in 2010. The goals of the waiver are to improve health care quality, control spending, and prepare California for health care reform implementation in 2014. One major part of the waiver is a plan to enroll certain seniors and people with disabilities (SPDs), including most people with HIV, into Medi-Cal managed care plans.
What is health care reform?
President Obama signed the ACA into law in March 2010. This law, commonly known as health care reform, dramatically expands health care coverage to uninsured and underinsured Americans. It also provides much needed protections and other positive changes to all the programs that make up the US health care system including Medicare, Medicaid, and individual and group insurance. It promises to significantly improve and stabilize health care coverage for people with HIV. Although the ACA is already law, many of its details are still being considered and put into place by federal and state agencies.
What is a Medi-Cal managed care plan?
There are two types of Medi-Cal: fee-for-service and managed care. In fee-for-service Medi-Cal, you select the doctors and other providers you want to see. However, finding doctors who will accept new Medi-Cal patients can be difficult because the programs pay very low doctors’ fees. Medi-Cal managed care plans have many types of providers — including doctors, specialists, pharmacies, clinics, labs, and hospitals — but you can only go to the providers that are in your plan.
The number of Medi-Cal managed care plans varies by county. Some counties have several plans to choose from while some have only one. If you have to move into a managed care plan, you will receive several notifications, including an enrollment packet explaining what is available in your county.
Who is required to join a Medi-Cal managed care plan?
You will have to take some action if you meet ALL of the following criteria:
- You live in Alameda, Contra Costa, Fresno, Kern, Kings, Los Angeles, Madera, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, Santa Clara, Stanislaus, or Tulare. (If you’re outside these counties, you do not have to join managed care.)
- You are enrolled in Medi-Cal because you are a senior or disabled, this includes most people with HIV. This category includes people:
- age 65 or older;
- blind, as determined by the Social Security Administration (SSA); and/or
- disabled, as determined by the SSA, including recipients of Supplemental Security Income (SSI).
- You are enrolled in Medi-Cal only; you are not enrolled in both Medicare and Medi-Cal.
- You have free Medi-Cal or you are enrolled in the Working While Disabled Medi-Cal program and pay a monthly premium of between $20 and $250. (If you do not know what kind of Medi-Cal you have, check with your eligibility worker or an advocate who can help you.)
What Medi-Cal Aid Codes are required to enroll in managed care?
Medi-Cal uses Aid Codes to identify people who are eligible for coverage. If any of the following codes apply to you, you are required to enroll in managed care: 20, 24, 26, 2E, 2H, 36, 60, 64, 66, 6A, 6C, 6E, 6G, 6H, 6J, 6N, 6P, 6V, 10, 14, 16, 1E, 1H.
Is anyone exempt from mandatory enrollment?
Yes. You do not have to enroll in a Medi-Cal managed care plan if:
You have both Medicare and Medi-Cal, also called “dual” or “Medi-Medi”;
You have other qualified health coverage in addition to Medi-Cal (private/group insurance; Ryan White coverage does not count);
- You are enrolled in a home and community based waiver program, including the AIDS Community-Based Waiver Program;
- You live in a long-term care facility, such as a skilled nursing facility; and/or
- You are a child enrolled in California Children’s Services.
- When will I be required to enroll in a managed care plan?
- The mandatory managed care enrollment process began on June 1, 2011.
- If you are currently enrolled in Medi-Cal: Enrollment in a managed care plan is based on your birth month. For example, if your birthday were October 2, you would be required to enroll in a managed care plan in the month of October.
- If you are new to Medi-Cal, you will be enrolled directly into a plan when you become eligible.
How do I enroll in a Medi-Cal managed care plan?
If you are new to Medi-Cal, enrollment will be done during your application process.
If you’re already in Medi-Cal, you will receive enrollment information from Medi-Cal. It is important to act on the information quickly. If you do not choose a plan by the deadline, you will be placed into a managed care plan by Medi-Cal. If you want to continue to see your current provider, find out which plans your provider is enrolled in and ask him or her to recommend a plan for you. If you are changing providers, contact the new provider and ask the same questions.
- Three months before your birth month, you will receive a notification letter, letting you know that you will need to choose a managed care plan. You will also receive a reminder phone call between 90 and 60 days before your birth month.
- Two months before your birth month, you will receive an enrollment packet. It is important that you review the information carefully and keep your packet for future reference, as it includes information on your county’s plan(s), your enrollment form, a Health Plan Comparison Chart, a Health Information Form, Health Plan Provider Directories, and the Medical Exemption Request (see below).
- Between 60 and 30 days before your birth month, if you have not made a health plan choice, you will receive another call to answer any questions you may have.
- A month before your birth month, if you still have not made a health plan choice, you will receive a reminder letter that includes your deadline for enrolling in a plan. If you do not make your choice by the deadline, Medi-Cal will place you in a managed care plan. Act early to avoid this “default” because it may mean that it will be difficult or even impossible to see your current doctor or use your pharmacy.
- If you want to enroll in a plan outside your mandatory enrollment period, contact Health Care Options at 800.430.4263.
Who can help me with this process?
You can ask questions and get help with enrollment by calling Health Care Options at 800.430.4263. Medi-Cal workers cannot help you with enrollment into managed care if you already have Medi-Cal.
If you want to continue care with your current provider, the best place to start is your doctor’s office or clinic. If you want to change doctors, check with the new office or clinic. Find out what managed care plan your doctor has contracted with and join that plan. If your doctor has contracted with more than one plan, ask the office administrator to recommend a plan for you.
What if my doctor is not in the managed care plan?
It is important to talk to your doctor and/or the managed care plan benefits department to find out if your medical providers are in the Medi-Cal managed care plan you are considering. If you see a doctor outside the county you live in, he or she will likely not be contracted with your county’s plan. Medi-Cal does allow out-of-county contracting, but plans are sometimes reluctant to do it. Check with your doctor to see if he or she is willing to explore contracting with a plan in your county.
If your doctor is not in a plan, the following two options may be available to you. (However, if your doctor works outside your county and cannot or will not contract with a plan in your county, the Medical Exemption Request is your only option for maintaining care with your current provider.)
1.  Medical Exemption Request (MER): People with HIV and other “complex medical conditions” are allowed to request a one-year exemption from managed care. Currently, to be eligible you must have:
- An HIV diagnosis certified by your doctor, and
- Medical evidence that your current health condition is “medically unstable.”
Unfortunately, Medi-Cal added this second criterion after the legislation was written and the waiver was approved. They have not established a definition of “medically stable” or criteria to meet that standard. At this time, we can only recommend that your doctor include as much information as possible to make the case that you need to continue to see him or her and supply any additional requested information within 30 days of the request.
If your MER is denied, you must immediately request a state hearing in order to remain with your doctor. If you do not initiate the hearing process, Medi-Cal will place (or “default”) you into a managed care plan.
Community advocates strongly oppose the barrier (proving “medical instability”) to continuing long-term provider/patient relationships during this transition to managed care. We will continue to work with Medi-Cal services, CMS, and legislative officials to ensure that this additional criterion is either removed or clarified and that transparent and fair criteria and review processes are in place.
2.  Continuity of Care: If you enroll in a managed care plan and want to continue to see your doctor, you may be able to do so for up to 12 months if your doctor is willing to work with your managed care plan and take payments from the plan, and has no quality-of-care issues. For complete information on how to request a continuity-of-care arrangement, see www.dhcs.ca.gov/individuals/Documents/MMCD_SPD/Accessibility/SPD_Extended_Continuity_of_Care_FAQs09022011.pdf.
What should I do if my MER is denied?
If your MER is denied, you can file for a state hearing. Do so as soon as possible after your MER is denied. If your denial comes after your deadline to apply for managed care, you may be automatically placed into a Medi-Cal managed care plan unless you file immediately for a state hearing. To learn more about your rights, see www.dhcs.ca.gov/formsandpubs/laws/Documents/JvR%20publication%204-09.pdf.
You will need to complete the Request for State Hearing form, found on the back of the Notice of Action that informs you your MER is denied. It is important to provide all of the necessary information. You may want to get help filling out the request from an advocate, friend, or family member, or from free legal services in your area. If English is not your first language, be sure to list your language and dialect on the form so you can get language assistance at your hearing. Keep a copy of the request you file.
You can send your request to:
- The county welfare department at the address shown on the Notice of Action;
- The California Department of Social Services, State Hearings Division, PO Box 944243, Mail Station 9-17-37, Sacramento, CA 94244-2430; or
- The State Hearings Division at fax number 916.651.5210 or 916.651.2789.
You can also make a toll-free call to request a State Hearing at 1.800.952.5253 (voice) or 1.800.952.8349 (TDD). For full instructions, see www.dss.cahwnet.gov/shd/PG1110.htm.
We recommend that you consult an advocate or free legal service to help you prepare for your hearing and ask them to attend the hearing with you.
How will I know if my enrollment is complete?
Whether you choose a health plan or one is chosen for you, you will receive a letter confirming your plan and the date of enrollment.
What happens if I do not select a plan by the deadline in my letter?
If you do not select a plan by the deadline, Medi-Cal will enroll you in a plan.
Why it is important for me to take action in the Medi-Cal managed care enrollment process?
In general, if you’re living with HIV, your health needs are more complex than average and you need more doctor’s visits, monitoring tests, and specialized care. The relationships you develop with your doctor and other medical providers, such as nurses and pharmacists, are very important to maintaining your health. In order to remain with your health care providers, you must make active choices as you move into managed care. (Almost 90% of people who were automatically enrolled in the first month of enrollment, July 2011, were not matched to a plan with their current provider.)
Can I change plans once I am enrolled?
Yes, you can change plans, but be aware that some counties have only two plans, so if your county has only one plan you will not be able to change. Check to see if your doctor and other providers are in the plan you want to move to. To change, contact Health Care Options at 800.430.4263. It is important to note that changing plans can be a lengthy process.
Will my benefits change when I enter a managed care plan?
You will not lose any benefits that you are already eligible for under Medi-Cal. Some health plans actually offer additional services. These services may include transportation, translation services, health education and wellness programs, disease management services, and nurse hotlines. Other services like these are things to consider when selecting a managed care plan.
How can I learn more about my enrollment choices?
Health Care Options helps people enroll in Medi-Cal managed care. Health Care Options is available online at www.healthcareoptions.dhcs.ca.gov and by phone at 800.430.4263 (English), 800.430.3003 (Spanish), or 800.430.7077 (TDD).