Dual Eligibles Transition Sparks Worries

California could set a national precedent with implementation of its Cal MediConnect duals demonstration project, which is scheduled to begin implementation April 1. Eventually the program will shift one million frail and elderly Californians into managed care plans.

The pilot project combines the disparate services and financing of Medicare and Medicaid (in California known as Medi-Cal) for people who are eligible for both programs. Beneficiaries — known as dual eligibles — would theoretically get better care and more services in an integrated approach, and the state would save money by combining the finances from the two entitlements.

California’s duals project, one of 15 state pilots approved by CMS to help design new approaches for coordinating care, is by far the largest in the country.

The pilot project has gone through extensive stakeholder meetings and government hearings and its launch date has been delayed several times in an effort to ensure the project runs as smoothly as possible for such a fragile population.

At the start of January, the state sent 90-day notices to approximately 456,000 Californians in eight pilot counties, letting them know changes were coming. Also in January, the state released its enrollment timeline for the project.

Those milestones have been greeted with a distinct lack of enthusiasm from advocates for seniors and the disabled. Concerns persist about this ambitious pilot project. Some advocates say providers, patients and health plans are confused about how this shift will happen and certainly aren’t prepared for changes of this magnitude.  

No official from the state Department of Health Care Services was available to discuss the issue or answer specific questions. However, DHCS staff members did release a general written response.

“The goal of this effort is to improve care coordination for these individuals and provide high quality services efficiently and effectively. The current system is fragmented, increasing the risk of confusion, delayed care and unnecessary costs. As we begin this transition, we are working to ensure that Cal MediConnect beneficiaries have the information and resources they want and need,” the email response said.

The program had an unexpected downsizing last week when CMS officials halted new enrollment in the special-needs plan of CalOptima. Since CalOptima is the only insurer for Orange County in the duals project, that temporarily trims the eight-county demonstration plan down to seven counties.

Orange County has the second-largest population of dual eligibles in California, so the state will have 57,000 fewer duals to handle in the transition, at least until CalOptima can meet CMS requirements.

Confusion, Concern Over Care

“We are extremely frustrated and disappointed with how things are progressing,” said Kevin Prindiville, deputy director of the National Senior Citizens Law Center, a national legal advocacy group with an Oakland office.

Prindiville said health plans, providers and other places beneficiaries might call don’t have the proper scripts in place to explain dual-eligibles’ options.

“The state needs to get those systems up and ready as soon as possible, and determine whether it’s right to keep sending out notices until they’re ready to handle it,” Prindiville said.

“It’s not just staffing the phone line, but making sure the recording makes sense. Does it send people to the right place? Then is that person able to answer questions? It involves training of the staff. People will start getting notices from Medicare, people will be calling 1-800-Medicare, and we don’t know if they’re ready,” Prindiville said.

He said Health Care Options, the section of DHCS that manages enrollment, does not appear to be prepared to handle phone calls from beneficiaries.

“There is supposed to be a dedicated call center with a dedicated phone number. That hasn’t happened yet,” Prindiville said. “When people call, they get this long phone tree with information that has nothing to do with this transition. Things just have not been prepared.”

All of that leaves beneficiaries and stakeholders concerned and confused, he said.

“This is step one, and there’s a crack in step one,” Prindiville said, “so this is raising our anxiety and raising anxiety in other stakeholders.”

Prindiville cites two previous fragile-population transitions the state has overseen: one for seniors and persons with disabilities and another for beneficiaries of the Adult Day Health Care program (which later became the Community Based Adult Services program). Both of those programs had administrative shortcomings that affected delivery of care for beneficiaries, Prindiville said.

“The SPDs and CBAS, those were a similar transition for the state, and we’re worried those lessons haven’t been learned,” he said. “We are not sure the state has properly prepared people for this. Already it’s a complicated process, and without being ready [for the transition], given this population, there will be harmful consequences to this,” he said.

In their written statement, DHCS officials said:

“Earlier efforts [such as the SPD and CBAS transitions] indicate that increasing the amount of outreach to health care providers can help increase the effectiveness of these types of transitions. We have worked to accomplish that goal during this effort. We’ve also worked to share information with the health plans sooner in the process. DHCS has worked to improve the clarity of our messaging about the impact of the transition on Medicare benefits.”

Meetings, Input and Execution

Prindiville said he hoped the state’s optimism bears out in practice, but the recent release of the enrollment timeline seems unrealistic, given what’s been done to date, he said.

“The timeline is just incredibly complex, there is variation from one county to the next, and the inability to communicate makes it hard to make decisions,” he said. “We wish there were a simpler enrollment strategy in place.”

Prindiville applauds DHCS for its extensive inclusion of stakeholders in the planning process for the duals demonstration project but said that input has not been solicited for quite some time now.

“The state has had a lot of meetings, and that was great. But the stakeholder process has changed over time,” Prindiville said. “There has been a lot less [collaborative] work over the last several months, and that’s now showing.”

Dual-eligibles are confused about when they might be able to opt out of the program, or what’s involved in their choices of plans within the program, Prindiville said.

“There has been a lot of discussion,” Prindiville said, “but when the rubber is meeting the road, the action and execution just aren’t there.”

DHCS officials, in their email response, said Cal MediConnect is ready for the transition.

“Cal MediConnect beneficiaries can contact the California Health Insurance Counseling & Advocacy Program (HICAP) to talk to a health insurance counselor about their choices. They can also call Health Care Options to select a different Cal MediConnect Plan or stay in Regular Medicare. They are informed of this when they receive their 60-Day Notice. Effective Apr. 1, 2014, there will be a Cal MediConnect Ombudsman call center with Customer Service Representatives trained specifically to handle Cal MediConnect,” the statement said.

Officials also said answers to frequently asked questions about transition choices are included in the 60-day notice, scheduled to go out Feb. 1.

Categories: Insight, Medi-Cal, Medicare