Mandatory Enrollment of Seniors and Persons with Disabilities in Medi-Cal Managed Care

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1 California s Protection & Advocacy System Mandatory Enrollment of Seniors and Persons with Disabilities in Medi-Cal Managed Care May 17, 2011, Pub # Q: I receive Medi-Cal. Will I have to enroll in managed care? A: Many seniors and persons with disabilities (approximately 380,000 people) will have to join a Medi-Cal managed care plan if they live in one of the 16 counties on the list below: Alameda Contra Costa Fresno Kern Kings Los Angeles Madera Riverside Sacramento San Bernardino San Diego San Francisco San Joaquin Santa Clara Stanislaus Tulare But not everyone in these counties will be affected. You do not have to enroll in a managed care plan if at least one of the following applies to you: 1. You have Medicare as well as Medi-Cal 2. You receive services from the California Children s Services (CCS) program 3. You receive foster care or adoption assistance benefits 4. You are enrolled in a private health care plan 5. You are in a long-term care facility such as a nursing home or intermediate care facility 6. You have a share of cost for Medi-Cal

2 Page 2 of 5 2. Q: When will these changes take effect? A: Mandatory enrollment will depend on your birth month. Mandatory enrollment will begin effective June 1, 2011, for people with birthdays in May; it will begin effective July 1, 2011, for people with birthdays in June, and so forth. This process will continue for one year, through May Q: What is managed care? A: Managed care means that you receive your health care from a managed care plan. A managed care plan is an organized network of health care providers, which emphasizes primary and preventive care. Hospitals, physicians and other health care providers are members of the network. The managed care plan can be public or private. 4. Q: Are there any benefits to managed care? A: Yes. Managed care plans can provide you with the following: Help coordinating your care Help finding primary care doctors and specialists Help finding a pharmacy Ongoing referrals to specialists Telephone advice nurses Customer service centers Support groups Health education programs to: o Quit smoking o Prevent and deal with drug and alcohol problems o Manage chronic pain o Eat well and exercise safely Help getting to and from medical appointments (non-medical transportation) 5. Q: If I m in managed care, can I keep the same doctors I have now? A: Ordinarily, your doctor must be part of the managed care network. However, the managed care network must provide you with continuity of care. What this means is that if you now have a doctor who is not part of the managed care network, you can keep that doctor; but only if the doctor is both willing to keep seeing you and willing to accept the managed care

3 Page 3 of 5 network s payment rate or the Medi-Cal fee-for-service rate, whichever is higher. The doctor becomes a part of the managed care network just for purposes of caring for you. The doctor will have access to network providers for purposes of referrals, etc. 6. Q: If I don't already have doctors I like, will the health plan provide ones who know about my disability? A: The Medi-Cal managed care plan can help you find a doctor's office that will meet your special needs. Your doctor and the health plan will be responsible for helping to coordinate your care. This includes helping you find the specialists you need. In addition, the managed care plan has telephone advice nurses to answer your health questions and customer service call centers to answer questions about your benefits. 7. Q: What if I don't like managed care can I get out? A: Maybe. You may be able to get an exception waiver if you are being treated for a complex medical condition, such as: a. Pregnancy b. Cancer c. Organ transplant (or are scheduled for one) d. Renal disease and have dialysis at least two times per week e. A disease that affects more than one organ system (such as diabetes) f. You are enrolled in a waiver to get skilled nursing services in your home g. You participate in an Adult Day Care Program h. You are HIV positive i. Other conditions may apply Under an exception waiver the managed care plan must allow you to receive services from a provider or providers who are not part of the managed care network. This is true whether or not the provider is willing to accept the managed care network s payment rate. To apply for an exception waiver, you and your doctor must complete an exception form and return it to Medi-Cal within 30 days of becoming eligible to enroll in a managed care plan. You are not eligible for an exception if your doctor is part of a Medi-Cal managed care plan in your area.

4 Page 4 of 5 8. Q: I live in a rural county without any Medi-Cal managed care plans. Will I have to enroll in a managed care plan? A: No. 9. Q: I receive Medi-Cal mental health services through the county mental health plan? Will this be affected? A: No. The mental health plan is an entirely separate managed care plan. You will now be enrolled in two Medi-Cal managed care plans the managed care plan described in this memo, and the mental health plan. 10. Q: How will I know what to do to enroll? A: You should be getting letters and phone calls beginning about 90 days before you are required to enroll. The letters and phone calls will explain the steps you need to take and the options for managed care providers in your area. 11. Q: I don t have to enroll in managed care but I want to. Is it possible for me to enroll voluntarily? Yes, as long as your county has at least one managed care network that accepts Medi-Cal. 12. Q: How can I find out more about the managed care plans in my area and pick the best one for me? A: You can find information about Medi-Cal managed care on the Health Care Options (California Department of Health Care Services) website: You can also call Health Care Options at: There are also contact numbers for languages other than English. Here is the list: Health Care Options (California Department of Health Care Services) Contact Numbers Language Phone Number Arabic Armenian

5 Page 5 of 5 Cambodian Cantonese English Farsi Hmong Korean Laotian Mandarin Russian Spanish Tagalog Vietnamese TDD

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