December 12, 2013
Area(s) of Interest: Access to Care Advocacy
As part of a multi-faceted Medi-Cal expansion, the California Department of Health Care Services (DHCS) will be transitioning roughly 600,000 enrollees with incomes at or below 133 percent of the federal poverty level from the Low Income Health Program (LIHP) to Medi-Cal managed care effective January 1, 2014.
LIHP is a county-based program established under California’s “Bridge to Reform” SS1115 Medicaid Demonstration Waiver, and was created to prepare for health coverage options authorized through the Affordable Care Act of 2010 (ACA). The program provides a basic level of health coverage for eligible adults between 19–64 years of age who don’t qualify for Medi-Cal and meet certain residency, income, and citizenship requirements.
These low-income Californians will be eligible in 2014 for the 100 percent federally-funded Medicaid expansion or subsidized health coverage through California’s health insurance exchange, Covered California. During the transition, 600,000 LIHP enrollees will shift from county-operated programs to a Medi-Cal Managed Care plan. Approximately 24,000 enrollees with incomes above 133 percent of the federal poverty level may be eligible to purchase coverage or qualify for tax credits and subsidies through Covered California.
Physicians should be aware that in order to be reimbursed for non-emergent services provided to patients who transition to a Medi-Cal managed care plan, they must be contracted with the plan for the Medi-Cal product. California law prohibits physicians from seeking reimbursement from Medi-Cal beneficiaries for any covered services provided by a Medi-Cal managed care plan. DHCS is making every attempt to enroll patients in plans with which their current physicians participate, however it may not always be possible.
Patients transitioned to Medi-Cal managed care plans are, however, protected by existing state continuity-of-care laws and policies. According to DHCS, transitioning LIHP beneficiaries have the right to request from the managed care plan 12 months of continuity of care with a specialist or primary care provider, regardless of whether they meet the continuity-of-care criteria criteria typically required under California law.
To help physicians understand and prepare for the transition, DHCS is recently hosted a series of webinars. The webinars are now available for on-demand playback. CMA recommends that physicians who treat LIHP patients watch at least the first webinar, “General Provider Training for the LIHP Transition,” which focuses on provider-specific guidance regarding changes to existing processes.
For more information on the LIHP transition, see the DHCS's LIHP transition webpage.
Contact: CMA's reimbursement helpline, (888) 401-5911 or firstname.lastname@example.org.