Medi-Cal SPD Transition FAQs

Important Medi-Cal Changes For People with Disabilities and Seniors

Most people with disabilities and seniors who have Medi-Cal only must enroll in a Medi-Cal Health Plan. You can choose which Medi-Cal Health Plan in your county you want to enroll in.

What is changing?

  • Beginning June 1, 2011, Medi-Cal fee-for-service seniors and persons with disabilities (SPDs) will be required to enroll in a Medi-Cal Managed Care Plan
  • Medi-Cal used to refer to this population as the aged, blind and disabled
  • Managed care enrollment will be implemented over a period of one year
  • This change will occur in 16 of California's most populated counties including: Los Angeles, San Bernardino, San Diego, Riverside, Alameda, Sacramento, Contra Costa, Fresno, Kern, Santa Clara, San Joaquin, Stanislaus, San Francisco, Tulare, Kings and Madera
  • Each county will have its own plans. All members will be given at least two health plans to choose from (a local or commercial plan). They will receive the same Medi-Cal covered services that they do today. Plans may have different quantity allowables and / or authorization processes (like CenCal and Partnership do today)

What is a Medi-Cal Health plan?

In a Medi-Cal Health Plan, you get care from the doctors, hospitals and providers in your Plan. You do not pay anything to join or be in a Medi-Cal Health Plan. You are still on Medi-Cal.

Do I need to change doctors and hospitals?

Maybe. You might be able to stay with both. Ask your doctors which Plans they take. Or call the Plans and ask. When you enroll, choose the Plan that your doctors and hospitals work with. Even if your doctor is not in your Plan, you may be able to keep seeing that doctor.

When do I need to enroll in a Medi-Cal Health Plan?

Medi-Cal will mail you more information 60 days before your birth month. You must choose a Medi-Cal Health Plan before or during your birth month. Your membership starts the following month.

Why is California making this change?

  • Because California will receive $10 billion in federal funds to invest in its healthcare delivery system
  • The State wants to use this money to prepare for national health care reform (a.k.a. Obamacare) and to help slow the rate of growth in health care costs associated with the Medi-Cal program

Which beneficiaries are NOT impacted by transition?

  • Medi-Medi's
  • CCS / Medi-Cal — only CCS members in Alameda, Los Angeles, and San Diego counties will be voluntary; all other CCS members are mandatory for managed care
  • Foster Children
  • OHC / Medi-Cal
  • Share of Cost (SOC) Medi-Cal
  • SPDs in Long Term Care Facilities (LTCs)
  • Any SPDs already residing in one of the State's (14) COHS county plans: CalOPTIMA, CenCal, Central Coast Alliance, Central California Alliance for Health, Gold Coast Health Plan, Health Plan of San Mateo or Partnership Health Plan

Who are the Affected Customers?

  • Medi-Cal estimates more than 400,000 SPD beneficiaries will be affected by this transition
  • Medi-Cal classifies SPDs according to various aid codes. These aid codes are used to determine coverage and eligibility for Medi-Cal services. There are currently (23) aid codes associated with this population

How will the change be implemented?

  • Mandatory enrollment will not occur all at once
  • There will be a 12-month staggered enrollment of beneficiaries based on their birth month
  • Medi-Cal will auto-assign members that do not "choose" a plan on their own, based on their current provider relationships
  • Members whose doctors are not contracted with either health plan will be enrolled based on Medi-Cal's algorithm (meaning preference to the local initiatives)

What is Medi-Cal doing to inform patients?

  • Medi-Cal will begin notifying customers about the change at least 90-days before their birthday
  • The rollout plan includes a combination of notification letters, choice packets, informational materials and phone calls from people that can assist with enrollment
  • The steps will proceed as follows:
          1) Coverage change letters mail out to members [90-days before enrollment]
          2) Follow-up phone calls are made
          3) Health plan choice packets are mailed to members [60-days before]
          4) Second phone follow-up calls are made
          5) Final letter reminders are mailed to members [30-days before enrollment]

How is Medi-Cal encouraging patients to select plans?

  • Ask their doctors and providers which plans they take
  • Look at which hospitals are contracted with the plans in their area
  • Ask their friends and family about their experiences with a particular health plan
  • Call the plans directly and inquire about benefits for SPDs
  • Beneficiaries have 3 ways to enroll:
         1) Call Health Care Options at 1-800-430-4263
         2) Complete & return choice forms by mail
         3) Go to a local Health Care Options presentation

What if I don't do anything?

If you do not enroll in a Medi-Cal Health Plan by the end of your birth month, Medi-Cal will choose one for you. Then, your new Medi-Cal Health Plan will send you a membership card.

I'm already in a Medi-Cal Health Plan. Do I need to do anything?

No, you do not need to do anything. Your health care will stay the same.

Patient Resources

  • Medi-Cal offers affected SPDs the following resources for problems with plans or access to care:

    - Call health plan's member service phone number
    - Call Health Plan Options @ 1-800-430-4263
    - Call Medi-Cal Managed Care Ombudsman @ 1-888-452-8609
       or email at mmcdpmb@dhcs.ca.gov
    - Call Medi-Cal for a State Hearing @ 1-800-952-5253

Status Update on Shield Contracts

 

* The information provided by Shield HealthCare is believed to be current and accurate as of January 2, 2012.