Managed Care During ICT

A client who is currently enrolled in Managed Care in the Sending County will only be able to access fee-for-service MC (which includes emergency care, family planning and Sexually Transmitted Disease (STD) services) in the Receiving County until the case is fully transferred and approved.

If the client needs non-emergency medical care, mental health services, routine pregnancy care, or prescription refills in the Receiving County before the effective date of disenrollment from his/her Sending County’s managed care plan, the EW must advise the client to contact the Managed Care Ombudsman Office for emergency disenrollment at 1-888-452-8609 or email to MMCDOmbudsmanOffice@dhcs.ca.gov.

When either the Sending or Receiving County becomes aware that the client has an urgent medical need, that county must immediately complete the Request For Change - Online Fillable Form on the Medi-Cal Managed Care Division (MMCD) Office of the State Ombudsman web page to request disenrollment of the current Sending County’s Managed Care and enrollment of the Receiving County’s Managed Care plan once a new residence county code is reflected in MEDS. If the need is for future months, MEDS will update the client’s record during the monthly MEDS renewal process. The client may also contact Health Care Options (HCO) at 1-800-430-4263 to request a plan change once the new county address is updated in MEDS.

If the MMCD Office of the Ombudsman can verify the client’s new residence county address on MEDS or verify with the Sending County that the Receiving County has been notified of the client’s new county address, the Office of the Ombudsman will initiate a disenrollment from the existing managed care plan on MEDS. The client may access fee-for-service Medi-Cal on the day after the Office of the Ombudsman has completed the disenrollment action.

If the client has complex medical condition or complicated pregnancy and needs to be exempt from managed care enrollment, he/she can directly contact HCO to request a medical exemption form or complete it Online and return it to HCO for evaluation of fee-for-service benefit in the new county of residence. Refer to Exemptions from Enrollment.

Managed Care Transition During ICT

If the Sending County is...	And the Receiving County is...	Then...
Fee-for-Service (FFS) Two-Plan Model (2-Plan) Geographic Managed Care (GMC) County Organized Health System (COHS) NOTE: Santa Clara County has the Two-Plan Model.	COHS	MEDS will automatically enroll the client into the COHS health plan effective the first of the month AFTER the MEDS update (i.e., residence address and new residence county code).
FFS 2-Plan GMC COHS	2-Plan GMC	MEDS will automatically disenroll the client from the Sending County health plan effective the first of the month AFTER the MEDS update (i.e., residence address and new residence county code), and
		The client will be on fee-for-service (FFS) Medi-Cal, and
		The client will receive new enrollment information within two weeks of the MEDS update. Mandatory clients must select a plan to prevent being defaulted into one.
FFS	FFS	Client will receive fee-for-service (FFS)
2-Plan		Medi-Cal.
GMC
COHS

NOTE: If the Sending County submits an address and residence county code change to MEDS after MEDS renewal, the beneficiary will retain the same benefits that he/she had in the Sending County for an additional month.

Urgent Disenrollment

The DHCS Medi-Cal Managed Care Office of the Ombudsman developed an online fillable form for counties to use for urgent requests including:

Enrollment
Disenrollment
Removal of 59 holds.

All standard non-urgent changes need to be submitted by the recipient or their authorized representative through Health Care Options at 1-800-430-4263.

County-Initiated Disenrollment

If a recipient moves to another county and is still enrolled in Managed Care in the county from which he or she moved, they will continue to have access to emergency services and any other coverage the Managed Care plan authorizes out-of-network until the ICT is processed and the recipient is disenrolled.

If the recipient needs non-emergent services in the ICT month in the new county, Eligibility Workers (EWs) can complete the Online Fillable Form. County-initiated disenrollment must be processed no later than three business days after the request is made.

Online Form Completion Criteria

The following criteria must be met before an online request for disenrollment can be made:

MEDS must reflect all current information (i.e., residence address, county code)
MEDS must show active coverage for the recipient.

If the information above is not correct in MEDS, the request may be denied.

Client-Initiated Disenrollment