Providers Not Impacted | For the time being, skilled nursing home facilities will not be impacted by the enrollment of current residents into Cal MediConnect even if the nursing home is not in the health plan’s network. Newly enrolled Cal MediConnect residents will not have to change facilities. Providers of either In-Home Supportive Services, Community-Based Adult Services or Multipurpose Senior Service Programs will not be immediately impacted by the enrollment of current patients into Cal MediConnect. Similar to skilled nursing home residents, program beneficiaries will not have to change providers based on network arrangements. In the long term, however, providers who do not contract with health plans may experience declining referrals, as plans encourage referral to contracted providers.
claim for the 20% co-pay to the patient’s Medi-Cal plan, or in some cases, Medicare will send these claims automatically to the Medi-Cal plan. Physicians do not need to be a part of the MediCal plan’s network to have these claims processed and paid.
Conclusion | Many physicians and provid-
ers will be impacted by patients enrolling in Cal MediConnect. In particular, physicians who decline (or are unable) to contract with a Cal MediConnect plan are likely to see their patients reassigned to in-network physicians, with the significant prospect of losing the patient relationships altogether. While existing physicians and providers can continue to see existing patients for a temporary period of time if they meet the continuity of care requirements, it is imperative for physicians to consider long-term options with respect to Cal MediConnect plans and dual eligibles. Physicians can receive additional information by contacting Cal MediConnect plans in their county or visiting www.calduals.org.
physicians who decline to contract with a Cal MediConnect plan are likely to see their patients reassigned to in-network physicians
Providers Impacted | Suppliers of transportation, durable medical
equipment and medical supplies must be in-network providers for Cal MediConnect enrollees. Home health and physical therapy providers must also be in-network providers for Cal MediConnect enrollees, and therefore out-of-network providers would lose patients upon Cal MediConnect enrollment. Providers prescribing medication covered by Medicare Part D can continue such prescribing under the provisions of continuity of care, which includes a 30-day supply of any existing Medicare Part D prescription. After this time frame, enrollees must switch to medication on the plan’s formulary. Financial and Billing Implications | If a patient actively declines Cal MediConnect, the patient can keep Medicare as it is but must choose a Medi-Cal plan to receive Medi-Cal benefits. For a physician, if your patient decides not to join a Cal MediConnect plan, the patient can continue to see you as a Medicare Fee-for-Service (FFS) physician. Even if your patient joins a Medi-Cal plan, the patient can continue to see you as the current Medicare provider. Medicare physicians do not need to be contracted with Medi-Cal to see dual eligibles. As stated earlier, the rate provided to the Medicare physician is generally 80% of the Medicare fee schedule. If a dual eligible patient declines to enroll in Cal MediConnect, the Medicare physician should bill for Medicare services as is the regular billing practice of the physician. If the patient is enrolled in a Medi-Cal managed care plan, the physician should continue to bill for Medicare services as is the regular billing practice of the physician. There is also no change to the process of handling “crossover claims,” or the amount not covered by Medicare, which is typically 80%. Providers need to send the crossover
In addition, physicians or providers can contact Nelson Hardiman, LLP for more information. 1 CA Health & Safety Code, Sec. 1373.96 Jennifer Davis is a law clerk with Nelson Hardiman, pending her forthcoming admission to the California State Bar. Working with and under the supervision of Nelson Hardiman attorneys, Jennifer’s practice focuses on transactional and regulatory matters for the firm’s healthcare clients. Jennifer has extensive experience with hospital administration, having served as Business Director for City of Hope prior to receiving her JD from UCLA. As Director, Jennifer managed the Departments of Anesthesiology and Surgery which included the divisions of Urologic Oncology, Surgical Oncology, Gynecologic Oncology, Neurosurgery, Orthopedic Surgery, Plastic Surgery, Thoracic Surgery, and Head and Neck Surgery. As Director of the Surgery Department, Jennifer managed the largest robotic-assisted surgical program worldwide. At City of Hope, Jennifer also managed the prostate, breast, brain tumor and gastrointestinal cancer programs. Jennifer also completed her MBA from UCLA. While completing this advanced degree, Jennifer created her own consulting company, which focused on fundraising and business plan development for local and national nonprofits.
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F RONT OF F IC E | P RAC T IC E M AN AG EM EN T
CAL MEDICONNECT AND SPECIFIC PROVIDER TYPES