Many people with disabilities receive medical care, including durable medical equipment and medical supplies, through California's Medi-Cal system. California is rolling out Mandatory Managed Care for people with disabilities and seniors. The questions and answers below outline who is affected and explain the basics regarding the transition. A big thank you to Disability Rights California for sharing this important information.
Written by Disability Rights California
California’s Protection & Advocacy System
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 14 counties on the list below:
Alameda
San Bernardino
Contra Costa
San Diego
Fresno
San Francisco
Kern
San Joaquin
Los Angeles
Santa Clara
Riverside
Stanislaus
Sacramento
Tulare
But not everyone in these counties will be affected. You do not have
to enroll in a managed care plan if:
1. You have Medicare as well as Medi-Cal
2. You receive services from the California Children’s Services
(CCS) program, or
3. You receive foster care or adoption assistance benefits
Q: When will these changes take effect?
A: Mandatory enrollment will depend on your birth month.
Mandatory enrollment will begin in June 2011 for people with
birthdays in June; it will begin in July for people with birthdays in July,
and so forth. This process will continue for one year, through May
2012.
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.
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)
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, 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
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.
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.
Q: What if I don't like managed care – can I get out?
A: No. However, if you have a “complex medical condition” the
managed care plan must provide continuous care with your current
provider for up to one year after you enroll in the managed care plan.
This is true whether or not the provider is willing to accept the
managed care network’s payment rate. The state is finalizing
requirements for this “exceptions process.”
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.
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.
Q: I don’t have to enroll in managed care but I want to. Is it
possible for me to enroll voluntarily?
A: Yes, as long as your county has at least one managed care network
that accepts Medi-Cal.
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)
You can also call Health Care Options at: 1-800-430-4263.
What if the managed care provider contracts with a durable medical equipment provider who does not have customized enough assistive technology that meets my needs? I have found that managed care providers offer only what their contracted DME provider offers.
ReplyDeleteAs we learn if/how Medi-Cal coverage will change for DME, we will share the information on the AT Blog and with AT Network members.
ReplyDelete