Changes to Medi-Cal in Santa Clara County

Provider news | Monday, June 23, 2014

Beginning July 1, 2014

What is changing?

Long-Term Services and Supports (LTSS) received by Medi-Cal beneficiaries are now being managed by Medi-Cal Managed Care health plans, together with medical and behavioral health benefits. California's Coordinated Care Initiative (CCI) brings current Medi-Cal benefits and LTSS benefits together to be managed by a single health plan. With implementation of the CCI, Managed Care health plans now manage medical, behavioral health and LTSS benefits, providing case management and care coordination across all of these benefits.

What is the Coordinated Care Initiative?

The objective of the CCI is to better coordinate care and make it simpler for beneficiaries to get the right care at the right time in the right place. The CCI has two parts:

Managed Long-Term Services and Supports (LTSS): Starts July 1, 2014. Medi-Cal Managed Care health plans are now responsible for managing Long-Term Services and Supports, providing beneficiaries with case management and care coordination across medical, behavioral health, and LTSS. Medi-Cal beneficiaries will be required to join a Medi-Cal managed care health plan to receive their Medi-Cal benefits, including LTSS and Medicare wrap-around benefits (if applicable).
Cal MediConnect: Starts January 1, 2015. For beneficiaries with both Medi-Cal and Medicare, all benefits, including LTSS, will be combined into a single health plan. Eligible beneficiaries will be required to either enroll in a Cal MediConnect plan or join a Medi-Cal managed care health plan.

Click here for more information on Managed Long-Term Services and Supports.

What isn't changing?

Medi-Cal benefits and LTSS benefits do not change. The change is in how these benefits will now be managed.

What are Long-Term Services and Supports?

In-Home Supportive Services (IHSS)are personal care services for people who are disabled, blind or aged 65+ and unable to live at home safely without help. Consumers self-direct their care (hire, fire their caregivers).
Community-Based Adult Services (CBAS)is daytime health care at centers that provide nursing, therapy, activities and meals for people with certain chronic health conditions. CBAS benefits are already managed by Medi-Cal managed care health plans.
Multipurpose Senior Services Program (MSSP)provides social and health care coordination services for people age 65 and older.
Long-Term Care Facilitiesprovide residential long-term custodial or skilled nursing care.

When does this happen and how will my patients be notified?

Your patients will transition to Medi-Cal Managed Care plans by birth month, starting in July. They will receive letters from the CA Department of Health Care Services, letting them know about the changes and telling them how to choose a Medi-Cal Managed Care health plan (if they are not currently enrolled in a health plan). Letters will be mailed beginning 3 months before their birth month.

Can patients in a long-term care facility (LTC) still be my patients?

Yes, if you are credentialed with the LTC and plan to see the patient while in the LTC. If you are not credentialed or if you do not plan to see the patient while in the LTC, let us know and we will work with you to transition this SCFHP member to a provider who can see them while in the LTC.

What if my patient has a Share of Cost for Medi-Cal?

For a patient in long-term care, the long-term care facility will continue to manage the share of cost as it does today. For patients with IHSS, these patients will continue to work with their caregivers and with Santa Clara County Social Services to manage share of cost as they do today.

What if I have a patient who doesn't have LTSS but needs this help?

You can refer your patient to the appropriate organization to apply for LTSS benefits:

In-Home Supportive Services (IHSS): 1-408-792-1600
Multipurpose Senior Services Program (MSSP): 1-408-350-3200
Community-Based Adult Services (CBAS): Contact SCFHP –1-800-260-2055
Long-Term Care (LTC): contact SCFHP – 1-800-874-1890

Does this change how I get paid?

No, this does not change how you get paid, except for patients in LTC. If you continue to see these patients, you will be paid under a fee-for-service (FFS) arrangement, versus capitation. For your other patients enrolled with Santa Clara Family Health Plan for Medi-Cal, you will continue to be paid as you are today. For patients with both Medicare and Medi-Cal, Medicare will continue to be the primary payer and Medi-Cal the secondary payer.