Regulators Lift Enrollment Freeze for CalOptima Dual Eligibles Plan

Orange County's CalOptima health insurance plan for residents who are eligible for both Medicare and Medi-Cal will reopen enrollment on Nov. 1, after federal regulators froze enrollment earlier this year, the Orange County Register reports (Shine, Orange County Register, 10/27).

Medi-Cal is California's Medicaid program.

Background

CalOptima is Orange County's only health plan participating in Cal MediConnect's demonstration project for dual eligibles (Gorn, California Healthline, 8/4).

However, CMS officials in January found "widespread and systemic" problems in CalOptima's program for seniors and individuals with disabilities during a 10-day audit. For example, the insurer:

• Denied legally required prescription coverage;
• Failed to process provider payments in a timely manner; and
• Failed to pay for covered emergency services.

CMS said CalOptima could not join the dual-eligibles project until it successfully completed the immediate corrective actions prescribed by CMS" (Gorn, California Healthline, 1/27).

In August, state officials announced that they would delay entry of Orange County into the eight-county duals demonstration project until at least January 2015 (California Healthline, 8/4).

Details of Reopening

In a statement on Monday, CalOptima CEO Michael Schrader said that regulators' decision to reopen enrollment marks significant improvements in the dual eligibles plan.

Regulators will assess the plan's progress in January 2015 (Orange County Register, 10/27).