New CA Program to Streamline Health Care for ‘Dual-Eligibles’

New CA Program to Streamline Health Care for ‘Dual-Eligibles’

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SAN BERNARDINO – When Effie George’s electric wheelchair stopped working, her ability to leave home without assistance also came to a halt.

“I couldn’t go to adult day care three times week, someone had to be at the house to help me get out [to the bus],” said George, 65, who missed many medical appointments. “I was just frantic all the time.”

George navigated the health care system unsuccessfully on her own before reaching out to Vivian Lopez, director of Loma Linda University Medical Center Adult Day Health Services.

Lopez explained, “She didn’t know that her physician actually has to give an order and say, yes, her wheelchair requires [fixing]. And that [order] goes to her insurer, Inland Empire Health Plan (IEHP), and IEHP will go to their contracted company. The company comes out and checks her wheelchair, sends the cost to IEHP, and then it gets fixed.”

Four months after breaking down, George’s wheelchair was finally repaired.

This process may soon become less complicated for George and the 50,000 residents of Riverside and San Bernardino counties eligible for Cal MediConnect, a program for individuals currently enrolled in both Medicare and Medi-Cal. Funded through the Affordable Care Act, Cal MediConnect will coordinate the care of “dual eligibles” -- low-income seniors and people with disabilities receiving both Medicare and Medi-Cal (California’s name for Medicaid) -- by combining both these programs and providing additional benefits.

Four months without an electric wheelchair took a toll on George. A manual wheelchair allowed her to get around her house. But with her family at work or school all day, she was unable to leave the house without assistance.

“She stayed home alone. Luckily, she is very high functioning and intelligent, and she is careful. She can fix herself a sandwich, even though she has the use of only one hand,” said Lopez. “We see the participants three, four, five times a week and we almost become their surrogate family and know about their healthcare and know of their health habits. “

Creating a system of coordinated care

On January 1, 2014, individuals who are dually eligible for Medicare and Medi-Cal began receiving notices in blue envelopes, informing them of their options under
Cal MediConnect.

Through California’s Coordinated Care Initiative, individuals can choose to fully integrate their benefits through Cal MediConnect. Although all dual eligible individuals must join the state’s Medi-Cal portion of the new program, individuals can choose to opt out of the Medicare part of the program and remain in their fee-for-service Medicare plan. (Those currently in Medicare Advantage plans, such as Kaiser’s, will not be affected).

“Some people do prefer to have their own freedom, to make their own decisions,” said Gilbert Sauceda, program manager for Riverside County Health Insurance Counseling and Advocacy Program (HICAP).

However, those opting out of the Medicare side of Cal MediConnect and stay in their old Medicare plan will lose the benefits of care coordination between the Medicare and Medi-Cal programs, experts said.

Sauceda explained that HICAP provides free one-on-one counseling and educational programs about Medicare options for California residents. They make language interpretation available in over 200 languages.

“What is good to know is that Cal MediConnect is really only one option that people have in arranging their Medicare and Medi-Cal benefits,” said Sauceda. “We help them with the research to figure out exactly how this is going to affect their benefits and if this is something they are truly interested in.”

After the initial letter in the blue envelope, dual eligibles will receive 30, 60, and 90-day notices.

“If you don’t do anything, [Cal MediConnect] is the plan that the state is going to assign you,” said Gilbert.

Fixing a “disorganized and difficult” system

Lilliana Ulmer’s 26-year old daughter is nonverbal and severely disabled. She manages her daughter’s complicated medical needs, which means she must be in constant contact with Medicare, Medi-Cal and Social Security.

“I am very proud to be her mom and to be her advocate at the same time but I have to tell you, this system is very disorganized and very difficult,” said Ulmer, who works part time while her daughter attends adult day care.

She recently received a letter from Medicare listing eight phone numbers for assistance. Attempting to find the correct one was a frustrating experience for Ulmer.

“There are not enough explanations out there for us,” said Ulmer. “I am still young, and I am still patient. My daughter is not able to do that. Am I going to be able to do this when I am 75-80 years old?”

Lilliana Ulmer and Effie George shared their testimonies as panelists during the recent ethnic media briefing and roundtable to discuss CCI and Cal MediConnect for both San Bernardino counties, organized by New America Media and held last March 6th at the Norman Feldheym Central Library in San Bernardino.

Gilbert Sauceda of Riverside County’s HICAP, was also among the speakers at this event, alongside community stakeholders and representatives of advisory groups working in the two counties, to prepare for Cal MediConnect’s implementation by April 1st.

It was the third in a series of media and community roundtables highlighting the unique stakes of CCI and Cal MediConnect, which is set to launch in seven California counties this year, including Alameda, San Mateo, Santa Clara, Los Angeles, San Diego, Riverside, and San Bernardino.

High hopes for Cal MediConnect

For Cal MediConnect beneficiaries in Riverside and San Bernardino counties, patients can choose either Inland Empire Health Plan [IEHP] or Molina Healthcare.

“The health plan is going to help you coordinate. They are going to be the one place that you can call where you are not going to be told to call someplace else to get your answer. That’s the biggest, most important part of the program--the biggest benefit,” said Ryan MacDonald, director of strategic communications and outreach for Harbage Consulting, which is working with the state’s Department of Health Care Services.

He emphasized, “You will no longer have to call Medicare or Medi-Cal if you join Cal MediConnect. You can call your health plan, you can call your care coordinator.”

Cal MediConnect members will receive a complete assessment on joining. The program will provide preventative care and services in their home and community, as well as vision coverage and transportation services they are currently not receiving.

Vivian Lopez said her recent experience working with IEHP and Molina Healthcare on behalf of her adult day care patients has given her high hopes for Cal MediConnect.

“We were scared to death to work with the health plans because we knew how difficult Medicare and Medical have been,” she said. “But once we got into it, it was so amazing. We wondered what in the world we would have done to advance the cause of our participants?”

Effie George, who waited four months for her wheelchair, is also optimistic about Cal MediConnect.

“This system is going to be a lot better than what I have now. It’s fine (now) but there are just some imperfections.”

This article is part of New America Media’s partnership with Harbage Consulting on this California-wide Cal MediConnect media campaign to support the Department of Health Care Services' stakeholder engagement efforts. Additional support for this initiative comes from The SCAN Foundation.