Cal MediConnect

Cal MediConnect
Name	Cal MediConnect
Caption	California dual-eligibles demonstration
Established	2014
Country	United States
State	California
Administered by	California Department of Health Care Services, Centers for Medicare & Medicaid Services
Type	Health care integration program

Cal MediConnect

Cal MediConnect was a California initiative to integrate Medicare and Medi-Cal benefits for individuals eligible for both programs. It aimed to coordinate care among Managed Care Organizations, hospitals, and long-term services and supports providers to reduce fragmentation and hospital readmissions. The demonstration involved partnerships between Centers for Medicare & Medicaid Services, the California Department of Health Care Services, county agencies, and numerous health plans.

Overview

Cal MediConnect operated as a demonstration aligned with national efforts such as the Dual Eligible Demonstration and the Affordable Care Act’s incentives for integrated care. The program targeted adults dually eligible for Medicare Part A, Medicare Part B, and California’s Medi-Cal program, seeking to provide a single coordinated benefit package via participating Medicare Advantage and Medicaid managed care plans. Stakeholders included provider systems like Kaiser Permanente, Sutter Health, Dignity Health, and Community Health Systems, along with advocacy groups such as AARP, Justice in Aging, and local Area Agencies on Aging.

History and Development

Cal MediConnect emerged from federal waivers and state-level reform dialogues influenced by prior demonstrations like the Program of All-Inclusive Care for the Elderly and concepts tested in the PACE (Program of All-Inclusive Care for the Elderly). Negotiations involved federal officials from Centers for Medicare & Medicaid Services and state policymakers in the California State Legislature and the Governor of California’s office. Implementation drew on lessons from demonstrations in states such as Minnesota, Massachusetts, and Texas, and intersected with broader California initiatives including Medi-Cal expansion under the Patient Protection and Affordable Care Act.

Program Structure and Eligibility

Enrollment targeted beneficiaries who were dually eligible for Medicare and Medi-Cal and resided in participating counties such as Los Angeles County, San Diego County, Santa Clara County, and San Francisco County. Participating organizations included a mix of Medicare Advantage plans and Medi-Cal managed care plans working under contract with the California Department of Health Care Services and oversight from Centers for Medicare & Medicaid Services. Eligibility rules considered criteria established in federal statutes like Social Security Act provisions governing Medicare and Medicaid, and coordination requirements referenced guidance from the Department of Health and Human Services.

Benefits and Services

Cal MediConnect plans were designed to coordinate acute care services delivered in hospitals such as UCLA Medical Center and Cedars-Sinai Medical Center, primary care through networks including Community Health Centers and Federally Qualified Health Centers, behavioral health services involving entities like County Behavioral Health Departments, and long-term services and supports delivered by home- and community-based providers. The benefit design sought to integrate services analogous to those in Medicare Advantage Special Needs Plans and drew upon models tested by organizations such as The Commonwealth Fund and Kaiser Family Foundation. Care coordination tools included electronic health records compatible with Health Information Exchange initiatives and partnerships with Area Agencies on Aging and Independent Living Centers.

Enrollment and Outreach

Outreach efforts engaged consumer advocacy organizations including AARP, Legal Aid Society affiliates, and local senior centers to inform beneficiaries about enrollment options like passive enrollment and active plan choice. Counties collaborated with county human services and county health departments to conduct outreach, while health plans ran marketing campaigns analogous to those by UnitedHealthcare and Humana. Enrollment processes were influenced by federal protections such as Medicare appeals and Medicaid fair hearing rights and by state-level consumer support entities like Health Consumer Alliance.

Outcomes and Evaluations

Evaluations of Cal MediConnect drew on methodology used by researchers affiliated with institutions such as University of California, San Francisco, RAND Corporation, Stanford University, and policy analysts at California HealthCare Foundation. Outcome measures included hospitalization rates, emergency department visits, nursing facility use, beneficiary satisfaction, and cost-shifting between Medicare and Medi-Cal. Reports compared results to benchmarks from Medicare Shared Savings Program initiatives and national dual-eligibles demonstrations overseen by Centers for Medicare & Medicaid Services.

Criticisms and Controversies

Criticism arose from advocacy groups including Justice in Aging, Legal Services Corporation-affiliated groups, and local disability rights organizations, focusing on issues such as network adequacy, continuity of long-term services, and the complexity of enrollment notices. Some providers and plans such as County hospitals and independent home health agencies raised concerns about payment rates and administrative burdens; observers compared these concerns to debates in Medicare Advantage and Managed Medicaid contexts. Legal and legislative debates in the California State Legislature and hearings with Centers for Medicare & Medicaid Services examined whether protections for dual eligibles met standards under federal statutes and state regulations.

Category:California health care programs