New Program Combines Medicare and Medi-Cal in Santa Clara County

New Program Combines Medicare and Medi-Cal in Santa Clara County

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SAN JOSE, Calif.--Santa Clara County is one of seven California counties participating in Cal MediConnect, a three-year pilot program that aims to help seniors and people with disabilities, who are eligible for both Medicare and Medicaid (Medi-Cal in California) medical programs, choose the health care that best fits their needs.

The main goal of Cal MediConnect’s is to coordinate the health and social care services that dual eligible (or “duals” as professionals call them) need. (For more information about Cal MediConnect.)

Existing System Difficult

“The existing system is extremely difficult to navigate for most people; there is lack of data to understand services; there is duplication; people are not getting the services they need,” said Sarah Steenhausen, Senior Policy Advisor of The SCAN Foundation.

She added, “This program is trying to promote a coordinated service delivery system for dual-eligible individuals, by improving care coordination, driving higher-quality care, and helping people stay healthy in their homes for as long as possible.”

The pilot program will include 456,000 duals, 39,000 in Santa Clara County. Among them 14 percent are Latino, ages 65 and older.

They started receiving blue envelopes from the California Department of Health Services back earlier in 2014. The blue envelopes contains important information about how to enroll, eligibility, and other questions dual eligibles may have about the program. The state is sending these notices 90, 60 and 30 days before the birthday month of each eligible person.

One of the challenges the program is facing is reaching out to its eligible population, and helping them understand the complex issues about how this program works. Many could easily mistake the blue envelopes with junk mail and discarded them.

“People receive an envelope and they think they have lost their coverage,” said Marty Lynch, Executive Director at Lifelong Medical Care based in Berkeley. “It is difficult to understand what’s going on. Our consumers bring these letters in and ask us, ‘What is going on?’ So don’t throw the blue envelope away.”

There are websites that have detailed information about the program, such as www.calduals.org, with information in multiple languages (including Spanish), or by calling 1-844-580-7272.

“We know language is a big issue,” said Sonali Parnami, representative of Santa Clara’s Aging Service Collaborate.

The collaborative is composed of over 80 organizations, such as On Lok Lifeways, which are attempting to connect the social services providers with the potential consumers.

“We are trying to identify what are the groups that need this information,” said Parnami, “because we know our county is so diverse and the language needs are so different, we try to have language representatives at our outreach events to try to answer the audience’s questions.”

Health-Plan Choices

Cal MediConnect includes both nonprofit and for-profit health care plans, depending on the county, which poses another challenge for the program.

Lynch, whose nonprofit Lifelong Medical Care serves mainly lower-income elders in Alameda county and who teaches public health at UC Berkeley, said Cal MediConnect may have problems overcoming mixed reviews for existing manage care plans.

“Doctors have gone through a long history of dealing with Medicare Advantage [HMO] Plans, some of which are good, some of which are terrible,” said Lynch. “So they are suspicious, especially of for-profit health plans, because they may do a good job, but their main goal is to take care of the stockholders.” Also, he said, some private doctors are a suspicious that they will be forced into receiving low payment rates from the state’s Medi-Cal program for the poor.

“That is not necessarily true,” said Lynch. “Another issue for [health care providers], is where is the care going to happen?” One lesson Lifelong Medical Care has learned, he explained, is to ensure then staff make decisions close to where the health care will actually be delivered to patients. If care coordinators aren’t close enough to where duals will receive care, he said, real care coordination won’t happen.

Dual eligibles will now have their plans coordinated under a single managed care entity. “People have different managed care plans to choose from depending on the county they live in, but they will enroll into one of those health plans with a range of services,” said Steenhausen.

The Cal MediConnect plans available for Santa Clara County are the Santa Clara Family Health Plan Cal MediConnect and Anthem Blue Cross.

San Mateo County, though, designated only one Cal MediConnect plan run by the country, Health Plan of San Mateo, because of its longstanding work as a model program for dual eligibles.

Coordinating Medicare and Medi-Cal

Dual-eligible beneficiaries can decline to sign up for Cal MediConnect, but they have to let the state know, or they will be automatically enrolled in the Cal MediConnect plan. People who get the blue envelopes can join initially and opt out of the program later, such as to go back to their existing medical program under traditional federal Medicare benefits.

In either case, though, duals who are not in Cal MediConnect must still be in an approved Medi-Cal managed care program under California’s new Coordinated Care Initiative.

Medicare is the federal health insurance program for people 65 or older and those unable to work due to disability, regardless of their income level. However, Medicare does not cover everything.

Cal MediConnect will coordinate Medicare’s health services with Medi-Cal’s long-term services and supports that can be non-medical in nature. It aids people in personal care, mobility needs, transportation, shopping assistance, “anything you need to function independently and remain in the community, or you can receive in an institutional setting,” said Steenhausen.

Cal MediConnect will have different enrollment dates for each county. Santa Clara’s implementation will begin in January 2015.

Duals in Santa Clara County who receive the blue envelopes can get free assistance in understanding the decisions they must make in Cal MediConnect by contacting the Health Insurance Counseling and Advocacy Program (HICAP), run by the nonprofit “Sourcewise.” The program answers questions and offers counseling in any language. Contact them at (408) 350-3200, or through their website: www.mysourcewise.com.

Gerardo Fernandez wrote this article for Alianza News in Silicon Valley supported by a New America Media reporting fellowship sponsored by The SCAN Foundation.