Health Care Options Enrollment Contractor

All plan enrollment and disenrollment functions are handled by the Health Care Options (HCO) contractor. The current HCO contractor is Maximus. MC recipients who need assistance with selecting, enrolling in or disenrolling from a plan can contact the HCO contractor at 1-800-430-4263, There are also HCO representatives stationed at BAC, North County, and South County District Offices to answer questions and provide assistance with enrollment and disenrollment.

Health Care Options Flyer

The HCO Flyer explains that certain MC individuals are required to enroll in one of the two Managed Care Plans. It also explains that if the client does not choose a plan within the required time frame, one will be chosen for them. The HCO flyer must be placed in all CalWORKs and MC Intake packets.

EW Role in the Managed Care Enrollment Process

To reduce plan defaults and client confusion, EWs must inform applicants and recipients of the MC Managed Care process and requirements at intake and at redetermination.

EWs must inform all applicants/recipients in mandatory CalWORKs and MC Aid Codes that:

They are required to enroll in one of the MCPs in Santa Clara County,
There are HCO representatives located in certain Intake office lobbies to answer questions and assist clients in making a choice,
If they do not attend the HCO presentation and choose a plan at that time, an enrollment packet will be mailed to them,
They must choose between the two plans within 30 days, otherwise a plan will be selected for them.

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.

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

Clients have the option to request urgent disenrollment by contacting the Medi-Cal Managed Care Ombudsman by phone at 1-888-452-8609, or by email to MMCDOmbudsmanOffice@dhcs.ca.gov. Requests made by phone before 5 pm will be processed no later than two business days after the request is made. Requests made by phone after 5 pm will be processed the following business day and be effective no later than two business days after the request is processed.

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.

Automatic Default Into a Managed Care Plan

After 30 days, individuals who do not return enrollment forms are automatically assigned to a plan. There are several criteria by which the plans are automatically assigned:

The plan must have a primary care service site within the individual's zip code area (time and distance for travel does not exceed 30 minutes or 10 miles),
Family members are usually assigned to a plan as a group, and
The plan must include a primary care provider with the capacity to accept new patients and the language capacity to meet the individual needs.

Disenrollment

HCO representatives are responsible for disenrolling clients from their MCP. Disenrollment, whether to another health plan or Fee-for-Service, normally takes 15 to 45 days.

Plan Identification Cards

Managed care health plans will issue an identification card to each plan participant.

Santa Clara Family Health Plan’s card includes the client’s name, an ID number, the date coverage started, and the Primary Care Provider’s name, address, and telephone number. On the back are instructions on what to do in case of an emergency.

The Anthem Blue Cross of California plan card also has information identifying the subscriber’s name, address, effective date of coverage, name, address, and telephone number for the assigned primary care doctor, Blue Cross 24-hour nurse advice line, and Blue Cross toll-free service line.

MC recipients should always provide BOTH their plastic MC BIC, and their managed care plan ID card when receiving medical services.