Medi-Cal Handbook page 15-1 15. 15.1 Fee-For-Service Health care is provided to certain Medi-Cal beneficiaries through Fee-For-Service benefits. This means that some Medi-Cal clients may receive medical care from an individual doctor, dentist, pharmacy, etc. of choice who accepts the client as a Medi-Cal patient. Medi-Cal Fee-For-Service benefits do not restrict or require that clients receive their medical care from specified health care providers. Fee-For-Service medical providers are individually reimbursed by Medi-Cal for specific services or procedures performed. 15.2 Medi-Cal Managed Care Health Plans Santa Clara County has a Two-Plan Model for Medi-Cal Managed Care. Both a local initiative and a commercial plan operate in Santa Clara County and several other counties. The local initiative is organized by the county s Board of Supervisors. The commercial plan is a private sector health plan selected by the California Department of Health Care Services (DHCS) through a competitive bidding process. Alternate managed care models include a County Organized Health System (COHS) model and a Geographic Managed Care (GMC) model. 15.2.1 Comprehensive Managed Care Goals The goals of a comprehensive managed care plan include: Providing timely access to primary care and other necessary services in a cost-effective manner, Improving the quality of care, Increasing utilization of clinical preventive services, and thus Reducing the unnecessary and costly use of emergency rooms for nonemergency medical care.
page 15-2 Medi-Cal Handbook Medi-Cal MCPs provide health services to patients within a specific geographic area. The health plans have their own clinics and participating primary care physicians. In return for a monthly capitation payment, the health plan contractor signs an agreement with DHCS to provide health services to enrolled Medi-Cal recipients. Medi-Cal beneficiaries who enroll in a Medi-Cal MCP must seek medical care from a participating physician and cannot go outside the plan for medical care. Exception: A Medi-Cal recipient enrolled in a Medi-Cal MCP may receive life-threatening emergency room care and certain non-covered services (e.g., dental care) from fee-for-service providers. 15.2.2 Membership Services Any questions regarding access to care and coverage must be directed to the plan's office. Each Medi-Cal MCP has a membership services office or telephone number, which enrollees may access for information regarding: Names and locations of the participating primary care physicians, Emergency and urgent care services, Location of participating clinics and pharmacies (if applicable), Grievances, Disenrollment procedures, and Any other questions regarding plan benefits. 15.3 Overview of the Managed Care Two-Plan Model The Medi-Cal Two-Plan Model of managed care is available to Medi-Cal beneficiaries in Santa Clara County. DHCS has contracted with two Managed Care Plans (MCP) to provide Santa Clara County s Medi-Cal services. One contract is with a local initiative - a publicly sponsored health plan cooperatively developed by local government, clinics, Revised: 8/13/15 Update # 15-19
Medi-Cal Handbook page 15-3 hospitals, physicians and other providers that historically have served the Medi-Cal population in the county. The other contract, awarded through competitive bidding, is with a commercial plan. Santa Clara County s two managed care plans are: SANTA CLARA FAMILY HEALTH PLAN - Local Initiative ANTHEM BLUE CROSS OF CALIFORNIA - Commercial plan 15.3.1 Mandatory Enrollment Enrollment in one of the two Managed Care Plans (MCP) is mandatory for beneficiaries who: Reside in the county, Receive full scope benefits, and Are not required to pay a share-of-cost (SOC). Medi-Cal beneficiaries eligible for benefits in the following zero SOC Aid Codes are required to enroll in one of the two MCPs for their medical care: CalWORKs: 30, 32, 33, 35, 38, 39, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3P, 3R, 3U, 3W, 54, 59 Refugees: 01, 02, 08 Medically Needy - 14, 24, 34, 3N, 64 Medically Indigent (MI) Children - 82 Federal Poverty Level Programs - 1H, 2H, 47, 6H, 6G, 72, 7A, 7X, 8P, 8R Waiver Program: 6V Pickle: 16, 26, 36, 66, 6A, 6C Pending SB 87: 1E, 2E, 6E, 6N, 6P SSI/SSP: 10, 20, 60. 15.3.2 Voluntary Aid Codes Medi-Cal beneficiaries who may enroll in managed care on a voluntary basis and receive fee-for-service Medi-Cal are: Children: Aid Codes 03, 04, 40, 42, 45, 4A, 4C, 4F, 4G, 4K, 4M, 5K, 7J Adult: 86 All Breast and Cervical Cancer Treatment Program beneficiaries.
page 15-4 Medi-Cal Handbook 15.3.3 Exemptions from Mandatory Enrollment/Voluntary Enrollment The following Medi-Cal beneficiaries are exempt from mandatory enrollment and will remain in Fee-For-Service: Foster Care, Adoption Assistance Program (AAP) or Kinship Guardianship Assistance Payment (KinGAP) program Beneficiaries with a Share of Cost (SOC) Dually eligible for Medicare and Medi-Cal Individuals with Other Health Coverage Medically Indigent program for pregnant women (Aid Code 86) Individuals receiving services from the California Children s Services (CCS) program in disability Aid Codes Note: After October 2011, individuals receiving CCS services in Two-Plan or GMC counties may be required to enroll in Managed Care. Individuals in skilled nursing facilities (Long Term Care) Beneficiaries eligible for emergency and/or pregnancy-related services only Beneficiaries with a complex or high-risk medical condition (this includes ANY PREGNANCY) who are in an established treatment relationship with a provider or providers who are not affiliated with either Two-Plan Model program. Native Americans, their household members and other people who qualify for services from an Indian Health Clinic. Beneficiaries accepted for case management under an AIDS Waiver or other Home and Community Based Services (HCBS) program (except for the Developmentally Disabled Services Waiver) Beneficiaries requiring services relating to a major organ transplant. Note: Beneficiaries with a Medicare HMO (OHC code F ) may not enroll in the Two-Model Plan unless the Medicare HMO is also a commercial plan or local initiative according to the Two-Plan Model, and the DHCS contract with the plan allows recipients to enroll in both the contractor s Medicare HMO and the Medi-Cal managed care plan.(this is not currently applicable in Santa Clara County as neither of Santa Clara County s plans are Medicare HMOs.) Revised: 8/13/15 Update # 15-19
Medi-Cal Handbook page 15-5 15.3.4 Health Care Options Enrollment Contractor-Maximus Enrollment/Disenrollment Function All Two-Plan Model enrollment and disenrollment functions are handled by the Department of Health Services Health Care Options (HCO) contractor. The current HCO contractor is Maximus. Medi-Cal recipients who need assistance with selecting, enrolling in or disenrolling from a plan are to contact the HCO contractor at 1-800-430-4263, weekdays from 8 a.m. - 5 p.m. Assistance is available in Spanish, Armenian, Russian, Tagalog, Korean, Arabic, Chinese - Mandarin and Cantonese dialects, Farsi, Hmong, and Cambodian. There are also HCO representatives stationed at AAC, North County and South County District Offices to answer questions and provide assistance with enrollment and disenrollment. Health Care Options Flyer The HCO Flyer explains that certain Medi-Cal beneficiaries are required to enroll in one of the two Managed Care Plans. It also explains that if the client does not choose a plan within the required timeframe, one will be chosen for them. The HCO flyer must be placed in all CalWORKs and family Medi-Cal Intake packets. The HCO flyer is also available in Spanish. Health Care Option Presentations To help beneficiaries make informed decisions, the State contractor, Maximus, makes health care option presentations at certain District Offices providing Intake functions. There are Health Care Options counselors on site during business hours at AAC, North County and South County to answer questions, provide packets and forms, help clients enroll in or change a plan, and assist with emergency disenrollments. A schedule is printed every month and is available from the Maximus representative at the District Office. A copy is also sent monthly to each District Office SSPM. Selection of a health plan and completion of the enrollment form should be made with the assistance of the HCO counselor at the time of application whenever possible. Each Medi-Cal applicant or beneficiary in a mandatory Aid Code who has a face-to-face interview with an EW must be referred to an HCO counselor for a presentation, at which time the client receives information about managed care and fee-for-service options available for the purpose of making an informed choice.
page 15-6 Medi-Cal Handbook 15.3.5 EW Role in the Managed Care Enrollment Process In order to reduce plan defaults and client confusion, EWs must inform applicants and recipients of the Medi-Cal Managed Care process and requirements at Intake and at Redetermination. EWs are to take a proactive role in ensuring each applicant or beneficiary attends an HCO presentation during the application process in order to select a Health Care Plan and Provider. This includes informing all applicants/recipients in mandatory CalWORKs and Medi-Cal Aid Codes that: They are required to enroll in one of the two MCPs in Santa Clara County, There are Health Care Options representatives co-located in certain Intake office lobbies to answer questions and assist clients in making a choice, If they do not attend the HCO presentation and choose a plan at that time, an enrollment packet will be mailed to them, Clients must make a choice between the two plans within 30 days, otherwise a plan will be selected for them (default) and An 800 number is also available for any questions they may have. HCO Referrals Each applicant or beneficiary who completes a face-to-face interview and is applying for a mandatory Aid Code program must be referred to an HCO representative for a presentation.the client will receive an individual or a group presentation depending on the situation, and language needs. During the HCO presentation, clients will receive: Information on managed care health plans/providers, and Assistance in completing the enrollment choice form. Note: It is NOT necessary for the application process to be completed, and the case granted/active prior to the HCO presentation. The completed Enrollment Choice form can be held by HCO staff up to 120 days prior to approval of benefits. Revised: 8/13/15 Update # 15-19
Medi-Cal Handbook page 15-7 15.3.6 HCO Referral Process HCO Referral Form The Health Care Options Referral Form (SCD 31) is used to refer clients who are completing a face-to-face interview at AAC, North County and South County district offices to co-located HCO staff for a presentation. This includes both mandatory and voluntary beneficiaries who request to be enrolled. The HCO referral process is as follows: Step Who Action 1. Reception Gives the SCD 31 to clients applying for CalWORKs or Medi-Cal to complete with the SAWS 1 and the SC 41. Informs client not to leave the office without an appointment letter. 2. Client Drops off the SAWS 1, SC 41 and SC 31 together in the drop-off basket after the forms have been completed. 3. CST Separates the SCD 31 from the other two forms and places the original SC 31 in the designated HCO basket. 4. HCO Counselor Picks up the SCD 31s on a flow basis Provides an HCO presentation, either individually or in a group in the designated area. Signs off the SCD 31 indicating whether or not the client attended an HCO presentation. Places the SC 31 in the designated basket for return to the EW. 5. EW Explains the requirement to attend an HCO presentation when interviewing the client. Provides additional information to the HCO counselor if requested. Requests the SC 31 be scanned into IDM when returned.
page 15-8 15.3.7 Enrollment Information Packet Medi-Cal Handbook Medi-Cal beneficiaries who are required to enroll in one of the Medi-Cal MCPs are mailed a packet of information that includes: An enrollment form with written notice of the requirement to select one of the two available MCPs, A list of scheduled presentations, Information about requesting an exemption from the mandatory enrollment requirement under certain conditions [Refer to Exemptions from Mandatory Enrollment/Voluntary Enrollment, page 15-4.] and A list of health care providers affiliated with each managed care network. This information will help recipients determine whether their personal doctor or clinic is affiliated with one of the two plans. Reminder: Clients who have a face-to-face interview are to be referred to attend an HCO presentation at the time of application, and should not wait until the enrollment packet is received before choosing a health care plan. Choosing a Primary Care Provider (PCP) Medi-Cal beneficiaries must select or be assigned to a Primary Care Provider (PCP) as well as to a plan. Some indicate their choice of a provider on their initial enrollment form. Others may enroll in a plan (or be assigned to a plan) before they select a PCP. In these cases, the plan must complete the process of PCP assignment. The plan will notify the beneficiary that he/she may choose a provider and, if the beneficiary does not make a selection within a specified time, the plan will assign a PCP. 15.3.8 Automatic Default Into a Managed Care Plan After 30 days, beneficiaries who do not return enrollment forms are defaulted, or automatically assigned to a plan based on a weighted assignment method. The weighted assignment method takes the following into consideration: The plan must have a primary care service site within the beneficiary s zip code area (time and distance for travel does not exceed 30 minutes or ten miles), Revised: 8/13/15 Update # 15-19
Medi-Cal Handbook page 15-9 Family members are usually assigned to a plan as a group, and The plan must include a primary care provider with the capacity to accept new patients and the language capacity to meet the beneficiary s needs. 15.3.9 Disenrollment All disenrollments are handled through the HCO contractor, Maximus at 1-800-430-4263.The HCO representative on site at AAC, North County or South County can also help with disenrollments. Disenrollment, whether to another health plan or to fee-for-service, normally takes 15 to 45 days. Some people may require faster disenrollment. Plans can FAX emergency disenrollment requests to the HCO contractor, which must process the disenrollment within two working days. The emergency disenrollment may be for, BUT IS NOT LIMITED TO, any of the following reasons: Foster Care child, Incarceration, Long Term Care, Member has relocated out of County, or is outside the plan s service area, Member is under a provider s care for pregnancy or complex medical treatment, Member has tested positive for HIV, or has received a diagnosis of AIDS, Renal dialysis or other service not covered under the plan s contract, or Member was erroneously defaulted into a plan. Enrollees may change plans by completing a new Medi-Cal Plan Choice Form, indicating their selection of a new health plan.the form is only available from the state HCO contractor. Maximus, the state s contractor must process the disenrollment request form within a day of receipt, according to the firm s contract, but it takes additional time for the disenrollment to take effect (It can take 30 days). 15.3.10 Two-Plan Model Identification Cards Both the Santa Clara Family Health Plan and Blue Cross of California will issue an identification card to the plan participant. Santa Clara Family Health Plan s card includes the client s name, an ID number, the date coverage started, and the Primary Care Provider s name, address, and telephone number. On the back are instructions on what to do in case of an emergency.
page 15-10 Medi-Cal Handbook The Blue Cross of California plan card also has identifying information, subscriber s name and address, effective date of coverage, the name, address and telephone number for the primary care doctor, Blue Cross 24 hour nurse advice line, and Blue Cross toll free service line. The Medi-Cal beneficiary must always carry BOTH their plastic Medi-Cal BIC and their managed care plan ID card with them in order to receive medical services. 15.3.11 Coding Other Health Coverage with a Mandatory Managed Care Plan and No Other Coverage When a client chooses one of the Two-Plan Model managed care plans as a Health Care Option (HCO) AND HAS NO Other Health Coverage (OHC), do not enter OHC information into CalWIN Data Collection. For example, the client may have selected Kaiser as a Provider under Santa Clara Family Health Plan; however, the OHC code is still N. The only time that Kaiser information should be entered into CalWIN is when it is a private or group health insurance plan. HCP Information on MEDS Both the Santa Clara Family Health Plan and Blue Cross of California as managed care plans, are reflected in the [HCP-NO] field on various MEDS screens as a three-digit numeric code as follows: Managed Care Plan Code for Santa Clara Family Health Plan: 309 Managed Care Plan Code for Blue Cross of California: 345 A two-digit numeric or alpha/numeric code in the [HCP-STAT] identifies a recipient s enrollment status in the associated managed care plan. [Refer to User s Guide to State Systems Handbook, HCP-STAT, page 12-47.] 15.3.12 Cost of Care in Managed Care Plans Covered benefits are provided at no charge to the recipient when enrolled in one of the managed care plans. Medi-Cal is responsible for payment to the plan for the periodic charges of coverage. Revised: 8/13/15 Update # 15-19
Medi-Cal Handbook page 15-11 15.3.13 Managed Care Plans and Health Care Options Contact Information and Verbal Client Contact Information Update [W&I 14005.36] Per Welfare & Institutions Code 14005.36 Eligibility Workers (EWs) will receive contact information updates by telephone, fax or email from Health Care Options (HCO) and Medi-Cal Managed Care Health Plans (MMCHP). The client information changes may include address changes, name changes, or telephone number changes. The HCO or MMCHP is responsible for obtaining the client s consent to share information and then inform the County that it has the client s consent. This will allow EWs to maintain the most up-to-date contact information for clients. The Eligibility Worker (EW) must take action as stated below to update client information if a representative from HCO or MMCHP contacts the County by telephone, fax or email: Consent The EW must confirm that the HCO, or MMCHP representative has the client s consent to share information. If the client provided consent then the EW must update the client s new information in CalWIN within two (2) business days of initial contact with HCO or MMCHP. No Consent If the HCO, or MMCHP indicates that they do not have consent to share information with the County or if the information is incomplete or incorrect, then the EW must contact the client to confirm the new information and update the information in CalWIN within five (5) business days of initial contact with HCO or MMCHP.
page 15-12 Medi-Cal Handbook 15.4 Managed Care for Mental Health Services 15.4.1 Overview Managed Care for Mental Health services was implemented in Santa Clara county effective June 1, 1998. The Medi-Cal Specialty Mental Health Service Consolidation Program was implemented on a flow basis in all California counties with the exception of Solano and San Mateo counties. All participating counties have now implemented the program. The program provides mental health services to ALL MEDI-CAL BENEFICIARIES IN THE COUNTY THROUGH A SINGLE, MANAGED CARE MENTAL HEALTH PLAN (MHP). The MHP is a managed care plan specializing in mental health services. The plan covers all age groups. 15.4.2 Santa Clara County s Mental Health Plan (MHP) The MHP for Santa Clara County is: Santa Clara County Mental Health Department 645 South Bascom Avenue San Jose, CA 95128 The toll free telephone number is: 1-800-704-0900 Individuals may call the mental health plan to get information about: Mental health plan services offered, How to access mental health services, A list of the mental health plan s psychiatrists, therapists and clinics, and What to do if they are unhappy about the service. 15.4.3 Automatic Enrollment in the Plan All Medi-Cal beneficiaries are automatically enrolled into the MHP. There are no options and no choices to be made by the Medi-Cal beneficiary. Revised: 8/13/15 Update # 15-19
Medi-Cal Handbook page 15-13 15.4.4 Mental Health Services Most mental health services must be pre-approved by the mental health plan before the psychiatrist or therapist can be reimbursed by Medi-Cal. This is a change from existing Medi-Cal procedures. Approval from the mental health plan can happen quickly if an individual needs mental health services right away. Prior approval is not required for hospital services when an individual needs hospital admission for emergency mental health treatment. When a Medi-Cal beneficiary thinks he/she might need mental health services, he/she should contact his/her family doctor, clinic, or the mental health plan. For people currently receiving mental health services from the county mental health system, there will be no change in how they receive their services. People currently receiving mental health services from any source other than the county mental health system,(i.e., private psychiatrists, therapists, community clinic, etc.) MUST CONTACT THEIR PSYCHIATRIST/THERAPIST/CLINIC TO CHECK IF THE SERVICES NEED TO BE PROVIDED BY THE COUNTY MHP.
page 15-14 Medi-Cal Handbook 15.5 Exemption Process for Pregnant Women That Move From Aid Code 44 to 3N During the Last Trimester Pregnant women with no other linkage are eligible for Section 1931(b) Medi-Cal only in their last trimester. Many pregnant women in this situation are eligible for the 200% Federal Poverty Level (FPL) program (Aid Code 44), restricted to pregnancy-related services only in the early part of their pregnancy. Some of these women become eligible for Section 1931(b) Aid Code 3N in their last trimester, which provides full scope benefits and are required to choose a health plan and enroll within a certain timeframe. If a plan is not chosen, they are automatically defaulted into a managed care health plan. Pregnant women in Aid Code 44, which provides restricted services, receive their prenatal care under Fee-For-Service (FFS). Section 1931(b) Aid Code 3N provides full scope coverage and requires enrollment in a Medi-Cal managed care plan. An Aid Code change during the pregnancy could result in a change in provider which may result in disruption to the continuity of their pregnancy-related care. Medi-Cal managed care has a medical exemption process in place to allow pregnant women to remain with their current provider even if they become eligible for full-scope benefits under the Section 1931(b) program. 15.5.1 Informing Requirements This population must be informed of their right to continue their prenatal care, including labor and delivery, under FFS when they become eligible for full-scope benefits under the Section 1931(b) program. The informing notice Important Information, Changes to your Medi-Cal overage during your pregnancy and after you give birth (MC 209) must be provided to pregnant women that move from Aid Code 44 to Aid Code 3N in the last trimester explaining that they need to contact HCO to apply for an exemption from Medi-Cal managed care requirements. The MC 209 must be mailed along with the Section 1931(b) approval notice of action (NOA). Note: Staff may also give the MC 209 to clients at the time Aid Code 44 is granted. Revised: 8/13/15 Update # 15-19
Medi-Cal Handbook page 15-15 15.5.2 Ad Hoc Listing A monthly Ad Hoc listing (DSR 43760) is available in Business Objects to identify pregnant women who move from Aid Code 44 to Aid Code 3N. This list is to be used as a tool to ensure each client in this group is informed of the Managed Care exemption process in a timely manner.