Implementation of 1115 Waiver/Transition of Seniors and Persons with Disabilities. Frequently Asked Questions

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1 Healthy San Diego Many Medi-Cal beneficiaries are mandated to enroll in a Medi-Cal Managed Care Plan. The benefit of being on a Medi-Cal Managed Care Plan is improved access to health care including specialists and care coordination. Although some services are covered by other programs, such as the County Behavioral Health Services, California Children s Services and Denti-Cal, the Medi- Cal Managed Care Plan ensures treatment is well coordinated and have a responsibility to ensure their members receive necessary health care. Beginning June, 2011, Medi-Cal members within the Seniors & Persons with Disabilities (SPD) group who are solely Medi-Cal beneficiaries (not dual coverage), must enroll in a Medi-Cal Managed Care Plan during their birthday month. The State of California will send beneficiaries plan information for one of the options available including Care 1 st, Community Health Group, Health Net, Molina and Kaiser Permanente. (If a beneficiary does not select a plan, the State has a process in place to select the member s plan for them.) Once a selection has taken place, the beneficiary is enrolled and contacted by their new health plan with a welcome call and next steps. Beneficiaries with both Medi-Cal and Medicare (dual eligible) are not required to enroll in a Medi-Cal Managed Care Plan. On a voluntary basis they can choose a Plan or remain on Fee for Service Medi-Cal and Medicare. If a beneficiary has a problem getting necessary care, members and providers should always contact the health plan s Customer Service Department first. In most cases the health plan can resolve any issues. Occasionally a member may feel their needs aren t being met and may need a third party to help break down a barrier. The Consumer Center for Health Education & Advocacy can help. The Consumer Center for Health Education & Advocacy works closely with the health plans and can help figure out where the barrier is and how to resolve the problem. The Consumer Center can be reached by calling (877)

2 Implementation of 1115 Waiver/Transition of Seniors and Persons with Disabilities Frequently Asked Questions Many Medi-Cal beneficiaries are mandated to enroll in a Medi-Cal Managed Care Plan. Some of the advantages of being on a Medi-Cal Managed Care Plan include easier access to health care, referrals to specialists and care coordination. The plans have a responsibility to make sure their members receive necessary health care. Some Medi-Cal benefits are covered by other programs, including services provided by the San Diego Regional Center, County Behavioral Health Services, California Children s Services and Denti-Cal. Though the Medi- Cal Managed Care Plan do not cover these services, they are responsible to ensure treatment is well coordinated. Below please find Frequently Asked Questions regarding the enrollment of the Seniors and Persons with Disabilities (SPD) transition to Medi-Cal Managed Care Plans. When is the enrollment date for SPD enrollees? Enrollment will begin June 1, 2011 and will be based upon the enrollee s birth month. What is the enrollment/notification process? The first notification is sent ninety days prior to the enrollee s birth month. For example, letters were sent March 1, 2011 for enrollee s with an effective date of June 1, The notification gives a brief explanation of the change in Medi-Cal coverage and encourages the enrollee to contact Health Care Options (HCO). The second notice is sent approximately sixty days prior to the effective date, and includes a Health Plan Choice Packet. The third and final letter is sent if no response is received notifying the enrollee that if they do not select a health plan, one will be chosen for them. Telephone calls are made to the enrollee after each notification to inform them of the Medi-Cal changes and answer any questions they may have. The members may choose a plan during any of these calls. What enrollees are affected by the change in Medi-Cal? This will affect SPD enrollees with only Medi-Cal coverage. This is not for dual-eligibles that also have Medicare. If an enrollee gets their health care through Fee for Service (FFS) Medi- Cal, they will be required to join a health plan. If they are currently in a health plan, they will no longer be able to choose FFS Medi-Cal coverage.

3 How can the enrollees choose a health plan? Enrollees can choose a health plan or change a health plan anytime in a number of ways. They can make a choice by going to the HCO website ( or by calling Health Care Options at They can also select a plan by filling out the health plan choice form that will be sent in the mail. They will also have the opportunity to choose over the phone when they are called regarding their health plan enrollment. Will health benefits change? All of the health care benefits and services that are currently covered will stay the same. Will the enrollees be able to keep their doctor? Whenever possible, the enrollees can keep their current physician. The health plan websites list participating Primary Care Physicians and Community Clinics. This information should be referenced when determining the best health plan to meet their medical needs. Will the enrollee continue to have access to prescription drugs? Yes, the enrollee will have access to prescription medication that is a covered Medi-Cal benefit. However, drug formularies vary by health plan. The formularies are listed on the health plans websites and should be referenced when determining the best health plan for an enrollee. What is the enrollment process if a health plan is not chosen? Every effort will be made to have the enrollees select a health plan prior to their effective date. If this does not occur, the State will choose a plan and Primary Care Physician based upon the enrollee s prior Medi-Cal utilization. They will match physicians the enrollee has been seeing with the plans provider networks to determine the most appropriate health plan option to assist in continuity of care. If there are any other questions, please reference the Department of Health Services website: Or call the Healthy San Diego Information Line at (619)

4 Your Health Plan Choices Standard Benefits Plan Network Hospitals* *Call your provider about using other locations in an emergency. Doctors you can choose Urgent Care Centers Pharmacies Vision Plan Assistance with public transportation Health Education Interpreter Services 24 Hr. Nurse Advice Line Care 1 st Health Plan Community Health Group Health Net Community Solutions, Inc (Health Net) Kaiser Permanente Molina Healthcare Medi-Cal Covered Services Medi-Cal Covered Services Medi-Cal Covered Services Medi-Cal Covered Services Medi-Cal Covered Services Fallbrook Hospital Paradise Valley Palomar Medical Center Pomerado Hospital Rady Children s Hospital San Diego Scripps Mercy Hospital Chula Vista Scripps Green Hospital Scripps Memorial Hospital Encinitas Scripps Memorial Hospital La Jolla Scripps Mercy Hospital Sharp Chula Vista Medical Center Sharp Coronado Hospital Sharp Grossmont Hospital Sharp Mary Birch Hospital for Women and Newborns Sharp Memorial Hospital Tri City Medical Center Call Member Services 1 (800) Call your provider during business hours. After hour locations, call 1 (800) Over 335 pharmacies countywide, including all major pharmacies, such as Vons, Wal-Mart, Rite Aid, Longs and independent neighborhood pharmacies. Many provide 24 hour home delivery. Call Member Services at 1 (800) Yes, Vision Plan at 1 (800) Call 1 (800) for free door to door transportation to medical appointments Health Education offers classes on many subjects including What to do if your child is sick. Multilingual brochures on over 17 topics. Member newsletters and an information line 1 (800) Spanish, Russian, Mandarin, Vietnamese, Armenian, Hmong, Cantonese. Other languages available through the language line services. Call Member Services 1 (800) Alvarado Hospital & Medical Center Fallbrook Hospital Palomar Medical Center Paradise Valley Hospital Pomerado Hospital Promise Hospital Rady s Children s Hospital San Diego Scripps-Chula Vista Hospital Scripps Clinic-Green Hospital Scripps-Encinitas Hospital Scripps-La Jolla Hospital Scripps- Mercy Hospital Sharp-Chula Vista Medical Center Sharp-Coronado Hospital Sharp-Grossmont Hospital Sharp-Mary Birch Hospital for Women Sharp Memorial Hospital Tri-City Medical Center Call Member Services 1 (800) Call your provider during business hours. After hours, call 1 (800) locations, including Longs, Sav-On, Vons, K-Mart, Wal-Mart, Rite Aid and independent pharmacies. Thirteen are open 24 hours and 105 make deliveries. Call Member Services at 1 (800) Yes, Vision Service Plan at 1 (800) Call 1 (800) for bus and trolley tokens for medical appointments. Over 20 topics offered in English, Spanish and Vietnamese. Call Member Services for information at 1(800) Spanish, Vietnamese, Cambodian & Tagalog. Other languages and help line for the hearing impaired available through Member Services at 1 (800) Alvarado Hospital & Medical Center Fallbrook Hospital Promise Hospital Rady s Children s Hospital San Diego Scripps-Chula Vista Hospital Scripps Clinic-Green Hospital Scripps-Encinitas Hospital Scripps-La Jolla Hospital Scripps- Mercy Hospital Tri-City Medical Center Call Member Services 1 (800) or go to Call your provider during business hours. After hours call 1 (800) Over 375 pharmacies including Albertson s, Alpine Pharmacy, Children s Hospital Pharmacy, Costco, CVS, K-Mart, Leo s Pharmacy, Longs, Med-Rx, NCHS San Marcos Health Center, Ralph s, Rite Aid, Sharp Reese-Steely Pharmacy, UCSD Medical Center Pharmacy, Vista Clinic Pharmacy, Vons, Walgreens, Wal-Mart, White Cross and more. Yes, Health Net Member Services, 1(800) Please call Health Net s Member Services Department at 1 (800) for assistance. Health education classes, community events, weight management, member newsletter, and written materials. Please call 1(800) Spanish, Arabic, Vietnamese, Tagalog, Farsi, Russian, Lao, Cantonese, Mandarin, Samoan, Cambodian, and other languages available through Member Services at 1(800) Help line for the hearing and speech impaired. 1(800) Kaiser Hospital Call Member Services 1 (800) Call your provider during business hours. After hours, call 1 (800) There is a pharmacy at every Kaiser Permanente location: San Diego, Bonita, Carlsbad, Clairemont, Eastlake, El Cajon, Escondido, La Mesa, Mission Bay, Otay Mesa, Point Loma, Rancho Bernardo, San Marcos, and Vista. Call Member Services at 1 (800) Yes, Vision Plan at 1 (800) Yes, written directions to Kaiser sites by car and bus are available. Call 1 (800) Yes, at Kaiser provider locations. Call Health Education at 1 (619) Contact 1 (800) for Interpreter Services. TTY information for hearing impaired; call 1 (619) Fallbrook Hospital Rady s Children s Hospital San Diego Scripps Chula Vista Hospital Scripps-Mercy Hospital Sharp-Chula Vista Medical Center Sharp-Coronado Hospital Sharp-Grossmont Hospital Sharp-Mary Birch Hospital for Women Sharp Memorial Hospital Tri-City Medical Center Call Member Services 1 (888) Call your Primary Care Provider during business hours. After hours call 1 (800) Molina has over 300 locations, including Sav-On, Rite Aid, Walgreens, Wal-Mart and many independent neighborhood pharmacies which provide 24-hour home delivery. Call Member Services at 1 (888) Call Member Services at 1 (888) for more information. Call Member Services at 1 (888) for more information. Molina offers Health Education classes including Motherhood Matters, Weight Management, Diabetes and Asthma. To receive more information on Health Education services in your area, call Molina at 1 (888) Spanish, Russian, Ukrainian, Vietnamese, Hmong, Mien, Lao, Cantonese, Filipino, and other languages available through the Language Line Services. Call Member Services at 1 (888) (800) (800) (800) (800) (800) Please make sure that the Health Plan you select has providers in your area. See the Health Plan s Provider Directory ***Please note that providers are subject to change***

5 Medi-Cal benefits can now be provided under a Medi-Cal Health Plan. All Medi-Cal Health plans offer standard Medi-Cal benefits: Member Services Every Medi-Cal Health Plan has a Member Services telephone number for the following services: To help you choose or change your Primary Care Physician To change your address or phone number For questions about your benefits or where services are available For complaints or grievances For assistance with public transportation What are other benefits? When you choose a Medi-Cal Health Plan, your Medi-Cal benefits stay the same. Other benefits include: Family Planning Services You can always get family planning services from ANY family planning provider accepting Medi-Cal.* Indian Health Centers American Indians and Alaskan natives can always get services through any Indian Health Center.* Dental Services Your BIC is good at any Medi-Cal dentist. Call DENTI-CAL at to find a Medi-Cal dentist. Well Child Check-Ups (CHDP) Call 1 (800) *Services do not require prior approval. How to resolve issues? Medi-Cal Ombudsman 1(888) Consumer Center for Health Education and Advocacy 1(877) State Department of Managed Health Care 1 (888) HMO-2219 Healthy San Diego Program (619) (message line) Medi-Cal Health Care Options In San Diego County This material is being provided to help you better understand your choices. It is not an endorsement of any specific Medi-Cal Health Plan. Welcome to Medi-Cal Managed Care Your Medi-Cal benefits can now be provided by a Medi-Cal Health Plan. A Medi-Cal Health Plan gives you access to a network of doctors, clinics, specialists, pharmacies and hospitals. How Does Managed Care Work? Each Medi-Cal Health Plan has a list of primary care providers you can choose from. If you have a doctor now, you will need to find out if that doctor belongs to a Medi-Cal Health Plan. Your primary care provider will be responsible for managing your overall health care needs and referring you to other doctors if needed. Who Can Join a Medi-Cal Health Plan? Anyone who is on Medi-Cal, lives in San Diego County, and has a qualifying aid code gets Medi-Cal Health Plan coverage. This chart and an enrollment packet are provided to all persons who, like you, qualify based on their current aid code(s). Use the information in this comparison chart and the enrollment packet to examine your health plan choices. To order an enrollment packet or for assistance in filling out a choice form, please call Translators are available. The TDD Line for the hearing impaired is There is no charge to join a health plan. What If There Is an Emergency? An emergency is defined as those services required for alleviation of severe pain, or immediate diagnosis and treatment of unforeseen medical conditions, which, if not immediately diagnosed and treated, would lead to disability or death. If you or someone in your family has an emergency, you should: Call your doctor, OR Go to the nearest emergency room, OR Call What About Behavioral Health Services? You can get behavioral health services (including mental health, alcohol and drug treatment, counseling, etc) in two ways. Call your health plan doctor, or call the San Diego County Access and Crisis Line at Other information For information about other health and social services in San Diego County, call Benefits Identification Card (BIC) Choosing a Medi-Cal Health Plan If you already have a doctor, check the provider directory to see if he/she works with a Medi-Cal Health Plan. Then ask these questions when you compare the health plans: Can I keep the same doctor if I already have one? Will it be easy to get to the doctor? The answers to these questions can help you decide which Medi-Cal Health Plan is best for you. If you do not find the answers, you can call the health plan member services hotline to get the information you need. County of San Diego Health and Human Services Agency P.O. Box San Diego, CA HHSA: HSD 5 (04/2011)

6 Healthy San Diego Medi-Cal Managed Healthcare in San Diego County Presented by SPD Work Team 1

7 Objective: Provide an Overview of Healthy San Diego (HSD) 2

8 HSD is the Medi-Cal managed care system in San Diego County. 3

9 Healthy San Diego Vision Patient choice selecting health plans Value added local involvement in assuring quality and access Local oversight problem solving and continuous quality improvement of the delivery system 4

10 This is a unique Partnership of: Consumers Providers Health Plans State Department of Health Care Services/Medi-Cal Managed Care Division County of San Diego Health and Human Services Agency 5

11 Current Participating Health Plans: Care1st Community Health Group Health Net Kaiser Permanente Molina 6

12 Focus of HSD Enrollment of new beneficiaries Each month over 6,000 persons are reached through Health Care Options presentations provided by county staff. Quality Improvement Ensuring recipients receiving quality service and care. 7

13 Enrollment As of February 2011 More than 429,000 Medi- Cal beneficiaries in San Diego County. Approximately 232,000 enrolled in a Healthy San Diego Health Plan. 8

14 HSD Advisory Committee Structure Board of Supervisors Chief Administrative Officer Director HHSA Joint Consumer & Professional Advisory Committee Quality Improvement Subcommittee SPD Work Team Behavioral Health WG San Diego Regional Center WG Enrollment WG Facility Site Review WG Health Education and Cultural/ Linguistics WG Health Plan WG 9

15 Community Collaborative There is a State mandate to coordinate Public Health and Managed Care. This is accomplished through Memorandums of Agreement (MOAs) 10

16 Memorandums of Agreement California Children Services Child Health and Disability Program Children s Emergency Shelter Care Facility (Polinsky Center) Community Epidemiology Hansen s Disease (Leprosy) Immunization Program Maternal and Child Health 11

17 Memorandums of Agreement (Cont) Behavioral Health Sexually Transmitted Disease Control Program Tuberculosis Control Program Office of Aids Coordination Women, Infants and Children (WIC) Providers in the County San Diego Regional Center 12

18 Seniors and Persons with Disabilities In 2011 Healthy San Diego Behavioral Health and San Diego Regional Center workgroups merged together to become the SPD Work Team. This was done to ensure a smooth transition for Medi-Cal beneficiaries who will be mandatory enrollees in managed care health plans. 13

19 Seniors and Persons with Disabilities SPD Work Team Beginning June 2011, all Medi-Cal only beneficiaries will be required to enroll in a Medi-Cal Managed Care Plan. The plans will be required to provide enhanced services to this new population. Care coordination will be more important than ever. The plans will be required to ensure care coordination even when the services are paid for by another program. Examples of programs covered separately are Specialty Mental Health, Alcohol & Drug, Dental, Developmental, and Home and Community Based Services. In 2011, Healthy San Diego developed the SPD Work Team which consists of representation from nearly every HHSA program in San Diego County. The purpose of this Work Team is to identify barriers and ensure care coordination. 14

20 Grievance System Each plan is required to have a grievance system. If member has a problem or issue, they can call their plan s Customer Service # or the Consumer Center for Health Education & Advocacy (CCHEA). The health plans and Consumer Center for Health Education and Advocacy work collaboratively to resolve beneficiary concerns. Care 1 st 1 (800) Community Health Group 1 (800) Health Net 1 (800) Kaiser 1 (800) Molina 1 (800) CCHEA 1 (877)

21 Questions 16