Overview of the Managed Care Two-Plan Model

Managed care plans available in Santa Clara County:

SANTA CLARA FAMILY HEALTH PLAN - Local Initiative
ANTHEM BLUE CROSS OF CALIFORNIA PARTNERSHIP PLAN - Commercial plan
KAISER FOUNDATION HEALTH PLAN- Commercial plan

Medi-Cal (MC) recipients who enroll in a MC Managed Care Plan (MCP) must seek medical care from a participating physician and cannot go outside the plan for medical care with the exception of life-threatening emergency room care and non-covered services (i.e. dental care).

To be eligible for Kaiser Health Plan enrollment, members must meet one of the following criteria:

They were a Kaiser member in the last twelve months,
They are an immediate family member of a current Kaiser Permanente member, including being a member's:

- Spouse or domestic partner;
- Dependent child under age 26;
- Stepchild under age 26;
- Disabled dependent over age 21;
- Parent or stepparent of a member under age 26;
- Grandparent, guardian, foster parent or other relative of a beneficiary under age 26, or

A foster child or former foster child,
Dual eligibles with both Medicare and Medi-Cal.

Fee-for-Service

Health care is provided to certain MC recipients through Fee-For-Service benefits. This means that some MC clients may receive medical care from an individual doctor, dentist, pharmacy, etc. of choice who accepts the client as a MC patient.

MC Fee-for-Service benefits do not restrict or require that clients receive their medical care from specified healthcare providers. Fee-for-Service medical providers are individually reimbursed by MC for specific services or procedures performed.

Not all providers accept Fee-for-Service MC. It is the client's responsibility to determine whether a provider accepts Fee-for-Service MC before treatment.

Medi-Cal Rx

Effective April 1, 2021, the Department of Health Care Services (DHCS) is transitioning all Medi-Cal Pharmacy services to the Fee for Service (FFS) delivery system – Medi-Cal Managed Care health plans will no longer manage the pharmacy part of the Medi-Cal benefit package. This new model of delivering Medi-Cal pharmacy benefits and services (administered by DHCS and contractor Magellan) will be identified collectively as “Medi-Cal Rx”. Medi-Cal Rx does not affect Programs of All-Inclusive Care for the Elderly (PACE) plans, Senior Care Action Network (SCAN) and Cal MediConnect health plans, or the Major Risk Medical Insurance Program (MRMIP). Individuals will need to present their Medi-Cal Beneficiary Identification Card (BIC) to access pharmacy services.

Medi-Cal Rx Customer Service Center line: 1-800-977-2273 or 711 for TTY.

Managed Care Enrollment

DHCS has standardized which aid code categories require mandatory managed care enrollment, voluntary enrollment, or are mandatory Fee-For-Service.

Mandatory Enrollment

Enrollment in one of the Managed Care Plans (MCP) is mandatory for individuals who:

Reside in the county,
Receive full-scope Medi-Cal benefits, and
Are not required to pay a share-of-cost (SOC).

Voluntary Enrollment

Enrollment is voluntary for some MC recipients and they will have the option to opt in or opt out of managed care enrollment.

Exemptions from Enrollment

The following MC Recipients are exempt from mandatory enrollment and will remain in Fee-for-Service:

Recipients with a Share of Cost (SOC), excluding LTC SOC.

Some special populations which can include individuals with a complex or high-risk medical condition (this includes ANY PREGNANCY) who must continue to be treated by a provider or providers who are not affiliated with either Two-Plan Model program may request an exemption.

See the DHCS website, or refer to the Aid Codes and Managed Care Enrollment Chart for additional information on managed care enrollment requirements.

Note: Individuals who do not enroll in a managed care plan will only be eligible for Fee-for-Service MC.

Managed Care Plan Providers are Not Other Health Coverage

The provider under an MCP should not be listed as Other Health Coverage in CalSAWS. For example, the client may have selected Kaiser as their Health Plan choice, however, the OHC code is still “N”. The only time that Kaiser information should be entered into CalSAWS is when it is a private or group health insurance plan.