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Cal MediConnect (Medicare-Medicaid Plan)

Nonparticipating Providers Overview


The Department of Health Care Services (DHCS), in conjunction with the Centers for Medicare and Medicaid Services (CMS), is launching a three-year demonstration to enroll beneficiaries who are covered by both Medicare and Medi-Cal (dual eligibles) into managed care health plans. Enrollment in the Duals Demonstration, now known as Cal MediConnect, begins no sooner than April 1, 2014. Health Net is participating in Cal MediConnect in Los Angeles and San Diego counties.

Health Net's Dual Eligible program goal is to improve the quality of care its Medicare Advantage (MA) and Medi-Cal managed care members receive by providing access to seamless, integrated care. The key component of Health Net's Dual Eligible program is to promote better care and improve alignment and coordination of MA and Medi-Cal benefits.

The information on this page is designed to help nonparticipating providers and their staff become more familiar with the Dual Eligible Demonstration and Health Net's Dual Eligible program.

Participating Provider Groups, IPAs, and Hospitals who would like information regarding participating in Health Net's Cal Medi Connect network can contact Health Net's Provider Network Management Department by telephone at (818) 543-9178. Individual physicians interested in participating in the Cal Medi Connect should contact their affiliated Participating Provider Group or IPA to see if they are participating.

Network Participation Request

Ancillary providers who would like to request participation in Health Net’s Cal Medi Connect network may click on this link for further information.

Websites

FAQs

FAQs


The following FAQs are subject to change based on regulatory changes, requirements, and
additional guidance from the Department of Health Care Services (DHCS) and the
Centers for Medicare and Medicaid Services (CMS).


What is the Dual Eligibles Demonstration?

DHCS, in conjunction with CMS, is launching a three-year demonstration to enroll beneficiaries who are covered by both Medicare and Medi-Cal (dual-eligibles) into managed care health plans. Enrollment in the Dual Eligible Demonstration, now known as Cal MediConnect, begins no sooner than April 1, 2014, in eight counties (Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara). Eligible beneficiaries will begin receiving notification of changes and choices starting in January 2014.

What is the goal of the Cal MediConnect?

The goal of Cal MediConnect is patient-centered care. DHCS, CMS and their plan partners want to improve access to care, coordination of services, ensure continuity of care and increase availability and access to home- and community-based services, so beneficiaries have better health outcomes and remain in their homes and communities as long as possible.

Who is eligible for Cal MediConnect?

Cal MediConnect is available to individuals who meet all of the following criteria:

  • Age 21 and older at the time of enrollment
  • Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D
  • Eligible for full Medi-Cal benefits
  • Reside in a Cal MediConnect county
How will dual-eligible individuals enroll in Cal MediConnect?

Enrollment in Cal MediConnect is voluntary and occurs through a passive enrollment process. The passive enrollment process is phased in with county-specific timelines. Eligible beneficiaries receive multiple notices describing their choices about enrolling in Cal MediConnect. Eligible beneficiaries who do not notify the state they choose to opt out and do not choose a Cal MediConnect plan are passively enrolled in Cal MediConnect by the state.

After Cal MediConnect enrollment begins, eligible beneficiaries may voluntarily enroll or opt out at any time without waiting for their assigned month of passive enrollment.

Are dual-eligible individuals exempt from passive enrollment?

Individuals who may enroll in Cal MediConnect, but are exempt from passive enrollment, include:

  • Those residing in certain rural ZIP codes in San Bernardino County where only one health plan operates
  • Those enrolled in the following programs only after they have disenrolled from the programs:
    • Medi-Cal waiver programs – AIDS, Assisted Living, In-Home Operations, and Nursing Facility/Acute Hospital
    • Program of All-Inclusive Care for the Elderly (PACE)
  • Those enrolled in a prepaid health plan that is a nonprofit health care plan with at least 3.5 million enrollees statewide, that owns or operates its own pharmacies and that provides medical services to enrollees through and exclusive contract with a single medical group in each specific geographic region in which it operates to provide services
What services are covered under Cal MediConnect?

Services include, but are not limited to:

  • All Medicare services
  • All Medi-Cal services
  • Long-term services and supports (LTSS), including In-Home Supportive Services (IHSS), Community-Based Adult Services (CBAS), long-term custodial care in nursing facilities, and Multipurpose Senior Services Program (MSSP) services
  • Mental health and substance abuse programs
What’s next and how can I stay informed?

Health Net is committed to providing current information on Cal MediConnect as it develops. Check Health Net’s provider website at www.healthnet.com/provider for updates. Information is also available on the CalDuals website at www.calduals.org and through CMS.




2012 FAQs


The following FAQs are subject to change based on regulatory changes, requirements, and
additional guidance from the Department of Health Care Services (DHCS) and the
Centers for Medicare and Medicaid Services (CMS).


What is the Dual Eligibles Demonstration?

DHCS, in conjunction with CMS, plans to enroll beneficiaries who are covered by both Medicare and Medi-Cal (dual eligibles) into managed care health plans. This is a three-year demonstration with Medi-Cal benefits beginning March 1, 2013, and Medicare benefits beginning June 1, 2013, subject to CMS approval.

What is the goal of the Dual Eligibles Demonstration?

The goal of the demonstration is patient-centered care. DHCS, CMS and their plan partners want to improve access to care, coordination of services, ensure continuity of care and increase availability and access to home and community based services, so beneficiaries have better health outcomes and remain in their homes and communities as long as possible.

Why was Health Net selected to participate in the Dual Eligibles Demonstration?

Health Net was selected to participate in the demonstration in Los Angeles and San Diego counties because Health Net has partnered with DHCS for more than 15 years in Los Angeles County and 17 years in San Diego County providing services to Medi-Cal beneficiaries, including the seniors and persons with disabilities (SPD) population. Health Net also provides Medicare benefits to dual eligible beneficiaries through its Dual Eligibles Special Needs Plan (SNP) in both counties. Health Net has experience providing high-quality care and services, and the expertise to successfully maximize the ability of dual eligible beneficiaries to remain in their homes and communities with appropriate services and supports.

How many Dual Eligible beneficiaries live in Los Angeles and San Diego Counties?

Los Angeles County has approximately 374,000 dual eligible beneficiaries and San Diego County has approximately 75,000.

What services are covered under the Dual Eligibles Demonstration?

Services include, but are not limited to:


  • All Medicare services
  • All Medi-Cal services
  • Long-term support services, including in-home supportive services (IHSS), Community- Based Adult Services (CBAS), long-term custodial care in nursing facilities, and Multipurpose Senior Services Program (MSSP) services
  • Mental health and substance abuse programs
Why should my patients join Health Net and the Dual Eligibles Demonstration?

Your patients will receive quality care and enhanced benefits with one health plan responsible for coordinating your patients' medical care, behavioral health care and social and supportive service needs. Managed care removes the uncertainty you and your patients may currently experience in trying to determine which agency—Medicare or Medi-Cal—to contact to coordinate care. Additionally, patients will have access to customer services via telephone for questions and assistance, 24-hours a day, 7 days a week, 365 days a year.

Why should I join a Health Net participating medical group or independent practice association (IPA)?

Providers within a managed care network experience consistent financial stability and administrative simplification, receiving regular payments from a single payer, with one billing address and one telephone number for questions and assistance. Additionally, it is important to realize that both the federal government and state of California are moving towards a managed care model for all government-sponsored programs for higher quality of services, support and efficiencies. Providers within a managed care network are better positioned to continue treating their Medi-Cal and Medicare beneficiaries over the long term.

Can I continue to see my patients if they enroll with Health Net?

If you do not contract with a Health Net participating medical group or IPA, you can continue to see your dual eligible patients for approximately 6 to 12 months through Health Net's continued access to care program upon request by your patients.

What should I do if I am interested in joining a Health Net medical group or IPA?

Health Net is currently evaluating participating medical groups and IPAs for inclusion in the dual eligible network for Los Angeles and San Diego counties. Once the network is established, Health Net will post information on Health Net's provider website for interested providers. For additional information regarding our networks, please contact Health Net Provider Network Management at (626) 683-6325.

What's next and how can I stay informed?

Currently, many details of the demonstration are unconfirmed. Health Net is committed to providing information as the demonstration moves forward and clarification is received on issues. Check Health Net's provider website at www.healthnet.com/provider for updates. Additional information on the dual eligibles demonstration is also available on the CalDuals website at www.calduals.org.

Resources

Resources

We are excited about participating in this innovative program, and we are in the process of preparing an infrastructure that will provide our members and health care providers with a high level of service.

Things You Need to Know:

  • Health plan rates have not yet been determined by the State; therefore we will provide additional information as we learn more.
  • The Cal MediConnect program and Health Net will coordinate your patients’ medical, behavioral, and social care needs.
  • This is a voluntary program; your patients can choose to opt out of the Medicare portion.
  • Our Health Net Provider Updates will be your source for the latest updates.

Documents

Websites


Homeless Resource Guides for Medi-Cal Members

The Affordable Care Act (ACA) expands Medi-Cal benefits to nearly all individuals with low incomes. Individuals experiencing homelessness can significantly benefit from this coverage expansion; however, they face a number of barriers when accessing needed care and require additional resources to effectively manage. In an effort to better assist participating providers and their partners with hospital and skilled nursing facility (SNF) discharges for the homeless population, Health Net’s Public Programs Department, has developed county-specific resource guides for providing Medi-Cal services to homeless individuals.

Homeless Resource Guides

County Addendums

Los Angeles (pdf)
San Diego (pdf)

Aids Waiver Contractor list (pdf)
CCT Lead Organizations (pdf)
Health Net SNF list (xlsx)

Coordinated Care Initiative

Coordinated Care Initiative

The State of California's Coordinated Care Initiative (CCI) places focus and delivery of health care for seniors and people with disabilities. Coordinated care offers members an easier way to get what they need, when they need it.

Two major components of the Coordinated Care Initiative include:

  • Cal MediConnect: A voluntary, three-year program designed to coordinate medical, mental health and behavioral health, and long-term services and supports (LTSS) under one plan for members eligible for both Medicare and Medi-Cal.
  • Managed Long-Term Services and Supports (MLTSS): Most Medi-Cal members, including those also eligible for Medicare, will be required to join a Medi-Cal health plan. They will then receive their LTSS benefits, including both home and community-based services (HCBS) and institutional-based services, as well as wrap-around benefits, through their health plan.

Health Net is ready to provide the assistance and services required to help our members stay safely and independently in their homes and communities. Whether it is medical care, long-term services and supports, home and community-based services, and other assistance, we are here to support you.

At the heart of the Coordinated Care Initiative is improving the lives of the people it touches. Health Net is committed to being a trusted partner in health, delivering choice, quality and support to all of our members.

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Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


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The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


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The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


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The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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Document Type - File naming convention
PPG Care Plans - careplan_hnsubidpersonid_yyyymmdd.pdf
CBAS Care Plan - cbascp_hnsubidpersonid_yyyymmdd.pdf
CBAS Assessment - cbasa_hnsubidpersonid_yyyymmdd.pdf
MSSP Assessment - msspa_hnsubidpersonid_yyyymmdd.pdf
MSSP Care Plan - msspcp_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Assessment - mctna_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Care Plan - mctncp_hnsubidpersonid_yyyymmdd.pdf
SNF MDS Form - snfmds_hnsubidpersonid_yyyymmdd.pdf
Note: hnsubidpersonid is the Health Net Subscriber ID and Person ID
File name example: careplan_R9999999900_20140505.pdf

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I have elected to upload a zipped folder of care coordination documents in a pdf format using the specified file naming convention as set forth below. I understand the importance of ensuring that the file names are accurate and that they accurately identify the member(s) that the care coordination document(s) is/are associated with. I have elect to upload of the attached documents and confirm submission using the review option. I certify that the files will be carefully audited and confirmed to be accurately named before confirming my upload. By confirming my upload, I am representing that the file(s) is/are named accurately.


Document Type - File naming convention
PPG Care Plans - careplan_hnsubidpersonid_yyyymmdd.pdf
CBAS Care Plan - cbascp_hnsubidpersonid_yyyymmdd.pdf
CBAS Assessment - cbasa_hnsubidpersonid_yyyymmdd.pdf
MSSP Assessment - msspa_hnsubidpersonid_yyyymmdd.pdf
MSSP Care Plan - msspcp_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Assessment - mctna_hnsubidpersonid_yyyymmdd.pdf
MSSP Connect the Needs Care Plan - mctncp_hnsubidpersonid_yyyymmdd.pdf
SNF MDS Form - snfmds_hnsubidpersonid_yyyymmdd.pdf
Note: hnsubidpersonid is the Health Net Subscriber ID and Person ID
File name example: careplan_R9999999900_20140505.pdf

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