Cal MediConnect FAQs

How do I know if I am eligible for Cal MediConnect?                                                                                                                        Answer: Most people with full Medicare and MC benefits (Dual Eligibles) can join a Cal MediConnect health plan. MC recipients in participating counties who receive LTSS, such as Multipurpose Senior Service Program (MSSP), Community-Based Adult Services (CBAS), IHSS, or who live in a nursing facility, will need to enroll in a managed care plan for those benefits. This applies both to those who opt out of Cal MediConnect and those who are not eligible.

• The following are not eligible for Cal MediConnect:
• Dual Eligible clients under 21.
• Dual Eligibles with partial benefits or other health coverage.
• Home and Community Based Services waiver enrollees (except MSSP; all others must disenroll from those programs to be eligible for the Cal MediConnect; will not be passively enrolled).
• Dual Eligibles with developmental disabilities.
• Dual Eligibles with End-Stage Renal Disease (exception for San Mateo & Orange).
• PACE and AIDS Health Care Foundation enrollees (who must disenroll from those programs to be eligible for the Cal MediConnect; will not be passively enrolled).
• Individuals receiving services through California’s regional centers or State developmental centers or intermediate care facilities for the developmentally disabled.
• Individuals residing in one of the Veterans Homes of California.

 How will I be notified of Cal MediConnect enrollment?                                                                                                                    Answer: If you need to select a new plan, you will receive three different notices, sent 90, 60 and 30 days ahead of your enrollment date. This is the same for clients in Cal MediConnect and clients in MC fee-for-service who need to choose a managed care plan for their LTSS.

The first notice (90-day notice) will alert you to the coming change.

The second notice (60-day notice) will come with a packet that has information about plan benefits and provider networks to help you select a plan. This will include a plan that is the best match for you based on how many of your current providers are included in a plan¡¦s provider network.

The third notice (30-day notice) will provide you with information about your specific plan. This will be the plan you have chosen based on the 60-day notice. If you did not make a selection, it will be the plan that is the best match.

Those clients who are NOT eligible for Cal MediConnect and who are already enrolled in a MC managed care plan will receive one notice prior to the change in their benefit package. This change is the LTSS program, which adds long-term services and supports to clients’ existing plan.

What are my enrollment options?                                                                                                                                                          Answer: Your enrollment date will depend on several factors, including which county you live in and whether you are already in a MC managed care plan. You will receive a choice form in your 60-day packet that you can use to select a plan. You can also call Health Care Options to enroll in a plan at
1-844-580-7272 or 1-800-430-7077 (TTY).

If you are eligible for Cal MediConnect, here are your options:

1. Enroll in Cal MediConnect. Combine your Medicare and MC benefits under one plan. Clients can access the same Medicare benefits that they could through a fee-for-service or Medicare Advantage plan.
2. Join a MC plan only. Your fee-for-service Medicare or Medicare Advantage plan remains as it is; however, you must enroll in a MC plan for your MC benefits.
3. Enroll in PACE. Only certain dual eligible clients are eligible for PACE; you must be 55 or older, live in your home or community setting, need a high level of care, and in a zip code served by a PACE health plan with openings.

Note: Those who are not eligible for Cal MediConnect or who opt out still must enroll in a MC managed care plan or PACE.

When do I need to enroll for Cal MediConnect?                                                                                                                         Answer: Enrollment dates will vary. You do not need to do anything until you receive your notices.

Can I keep my providers?                                                                                                                                                                        Answer: Your new Cal MediConnect or MC health plan is required to make sure your care continues and is not disrupted. Your health plan will work with you and your doctors to make sure you get all the care you need.

You have the right to continue to receive needed services, even if you may no longer be able to receive them from the same provider. Eventually, you must get all your covered services from providers who work with your plan. These are in-network providers.

If your primary care or specialist doctor is not in your plan, you may be able to continue to see them for 6 months for Medicare services and 12 months for MC services as long as:

• You have seen the doctor twice in the 12 months before enrolling in the plan,
• Your doctor is willing to work with the plan and accept payment from them, and
• Your doctor is not excluded from your plan for quality or other reasons.

You have the right to stay in your current nursing home under Cal MediConnect, unless it is excluded from the plan’s network for quality or other concerns.

You will not have to change IHSS, CBAS, and MSSP providers.

Continuity of care protections do not apply to suppliers of medical equipment, medical supplies, and transportation. They also do not apply to home health or physical therapy providers.

Why did I receive a letter that states I will be disenrolled from my prescription (Part D) coverage?                                        Answer: If you qualify for both Medicare and MC, you will be automatically matched with (and eventually enrolled into) a Cal MediConnect plan, unless you otherwise choose to keep your Medicare they way it is now and choose a plan for your MC benefits, or if you choose a PACE plan. Since you can only be in one Medicare plan at a time, your enrollment in Cal MediConnect will automatically end your enrollment in any other Medicare prescription drug plan. Your Part D prescription drug coverage will then be covered by a Cal MediConnect plan.

You receive the disenrollment notice because your current Medicare program recognizes that you are scheduled to join Cal MediConnect, and is alerting you that your coverage will switch to that new plan once your new coverage begins. You will not lose your prescription drug coverage at any time.

If you do not want to be in Cal MediConnect, you may keep your Medicare the same and stay in your current prescription drug plan. You will still have to select a MC plan for your MC benefits. You just need to let Health Care Options know your decision.

What information should I consider in making this decision?                                                                                                          Answer: Your 60-day packet will contain information to help you make your decision, including identifying health plans that may be the best fit with your current doctors and other health care providers. You should contact this health plan’s member services phone number to be sure your doctor(s) and other health care providers that you use are in the plan’s network. If you want to find a new doctor, the health plan can help you find one.

You will also want to make sure that the Cal MediConnect health plan’s Medicare Prescription Drug formulary includes the medications that you need to take. Be sure to have the exact name of the prescription drug when calling the plan(s).

You may also want to talk with family members, your doctor(s) or other people you rely on in making this decision. Individual counseling is also available from the local Health Insurance Counseling and Advocacy Program (HICAP).

Where can I get more information and how can I exercise my options?                                                                                         Answer: Health Care Options staff can also help you to understand these new options and MC changes, and to enroll in the managed care of your choice. They can be reached at 1-844-580-7272.

The Cal MediConnect Ombudsman Program helps clients voice complaints and solve problems with Cal MediConnect. If you need help with your services or your plan, you can call 1-855-501-3077 (TTY 1-855-874-7914) from Monday - Friday, 9am - 5pm.

HICAP is available to help you understand these changes and new options. HICAP provides workshops on Medicare issues, including Cal MediConnect, and also provides individual counseling to assist individuals in understanding their options. You can call 1-800-434-0222 to talk with someone at your local HICAP.