Big Changes Coming to Fee-for-Service Medi-Cal
Updated January 6, 2022
If your child is a Medi-Cal recipient with private health care coverage, you may have heard that you’ll soon be required to assign your child’s Medi-Cal to a managed care plan instead of “fee-for-service” Medi-Cal coverage.
This is a big change. For over a decade, Medi-Cal recipients with Other Health Coverage (OHC) have been exempt from mandatory enrollment in a managed care plan. On January 1, 2022, however, a program called CalAIM went into effect. Among other things, the program is designed to streamline the delivery of Medi-Cal services in the community. Going forward, only those with medical exemptions will be eligible to remain under fee-for-service Medi-Cal.
The program is staged to take place over the next three years. According to the Department of Health Care Services, people with Supplemental Security Income (SSI)-linked Medi-Cal will see the change go into effect on January 1, 2022. For those who are enrolled in a Medi-Cal Home and Community-Based Services (HCBS) waiver — including the Regional Center institutional deeming waiver — and for those who are dually eligible for Medi-Cal and Medicare, the change won’t take effect until January 1, 2023.
- If your child has SSI-linked Medi-Cal and you’ve been notified that you must select a plan by January 1, 2022, you can call Medi-Cal Health Care Options at (800) 430-4263 to make your enrollment choice. If your child is a Medi-Cal waiver program recipient and you are being told that they must enroll in a managed care plan effective January 1, 2022, you should call the Medi-Cal Managed Care Ombudsman at (888) 452-8609 so they can make sure your child’s aid code is correct in their computer system. Only recipients of SSI-linked Medi-Cal are required to make the switch at this time. Make sure you have your child’s Benefits ID Card (BIC) available when you call.
- If you feel your child may qualify for a medical exemption, make sure you review the exemption criteria and discuss them with your child’s doctor. (You may also reach out to your Navigator to ask about a free 15-minute consultation with our public benefits specialist.)
We are continuing to seek updated information about how these changes may affect children with disabilities who have private primary insurance.
Note that children with complex medical conditions will receive enhanced care management services from the managed care plan to assist in the coordination of benefits. We’re working on identifying the parameters as to which children will receive enhanced care management. We were told that the state intends for the burden of this coordination process to fall on the managed care plans, not on parents of kids with complex medical needs. However, having a foundational understanding of these processes can empower you to advocate for your child.
Things may change, as we still have a year to go before implementation, but below are some issues that may arise during and after the transition:
- Currently, the Regional Center funds ABA services for children enrolled in fee-for-service Medi-Cal if their primary insurance will not cover ABA. Most often, this is because the child does not have an autism diagnosis. Children in a Medi-Cal managed care plan are covered for necessary ABA services regardless of diagnosis. Once your child is enrolled in a plan, you will need to use a provider who is contracted with that plan. A few months before the transition, you can talk to your provider about whether they intend to contract with a Medi-Cal managed care plan, or you can request that they contract with the plan you are going to choose. However, a provider cannot be required to contract with Medi-Cal.
- Children receiving home nursing services will have a reassessment by the managed care plan to ensure that they are receiving the right number of hours. It is the managed care plan’s responsibility to make sure the hours are staffed. You may need to ask whether your current agency will contract with your managed care plan. If this sounds confusing, that’s because it is! We are still researching this issue and will bring you information as we receive it.
- Children who are in active treatment for an acute medical condition can request continuity of care for up to 12 months if the provider is willing to contract with the plan and they can agree on a rate. If the child is not in active care (e.g., the child is in remission or being monitored long-term), they will be transitioned to a physician of the same specialty within the managed care plan. If the managed care plan does not have the appropriate specialist, they need to contract with one; you can request that they enter into a single-case agreement with the existing provider.
- Pharmacy and incontinence supplies will continue to be provided through fee-for-service Medi-Cal even for those enrolled in a plan.
- Durable Medical Equipment (DME) should be purchased from a supplier who accepts both the private insurance and the managed care plan. After the private primary plan pays its part, the managed care plan should pay the out-of-pocket portion up to the Medi-Cal rate, even if the prescription came from an out-of-network provider. You should not be billed for any unpaid balance after the primary insurance and the managed care plan have paid their portion. You should work with your plan’s enhanced care management coordinator if you have concerns about funding DME.
We hope this clarifies the upcoming changes to Medi-Cal enrollment. We realize you may still have questions about how coverage and coordination of benefits will work for children who have a private PPO as their primary insurance and Medi-Cal managed care as their secondary coverage. We have the same questions! As always, we are working hard to get more information and bring it back to you.