Cal. WIC § 14184.208 — California Code / Code wic / Division 9 / Part 3 / Chapter 7 / Article 5.51 / Section 14184.208
Section 14184.208
Status: in_force

(a) To promote more integrated care for dual eligible beneficiaries, the department shall seek to align the enrollment of dual eligible beneficiaries in affiliated Medi-Cal managed care plans and Medicare plans, including Medicare Advantage Dual Special Needs Plans (D-SNP), as described in this section and in accordance with the CalAIM Terms and Conditions. A dual eligible beneficiary shall not be required to enroll in a D-SNP for purposes of receiving their Medi-Cal benefits.

(b) (1) Commencing January 1, 2023, subject to subdivision (f) of Section 14184.102, the department shall require each Medi-Cal managed care plan operating in Coordinated Care Initiative counties to operate, or continue to operate, a D-SNP in accordance with the CalAIM Terms and Conditions, and in accordance with federal requirements for each D-SNP, to have an executed contract with the department, referred to as a State Medicaid Agency Contract (SMAC). The requirements described in this paragraph shall not be applicable to a subcontracted delegate health plan.

(2) In Coordinated Care Initiative counties, beginning in contract year 2023, the department may only contract with a proposed D-SNP that is affiliated with a Medi-Cal managed care plan or a subcontracted delegate health plan, or was contracted with the department for a D-SNP in contract year 2022 in the proposed D-SNP service area.

(3) In Coordinated Care Initiative counties, beginning with contract year 2023, dual eligible beneficiaries that are not already enrolled in a D-SNP for contract year 2022 may only enroll in a D-SNP that is affiliated with a Medi-Cal managed care plan or a subcontracted delegate health plan in the beneficiary’s service area.

(4) In Coordinated Care Initiative counties, beginning with contract year 2023, a dual eligible beneficiary shall be assigned to a Medi-Cal managed care plan, or subcontracted delegate health plan, that is affiliated with the Medicare Advantage plan, including a D-SNP, in which the dual eligible beneficiary is enrolled. The department may approve exceptions to this policy, to support beneficiary enrollment choice.

(c) (1) Commencing January 1, 2026, subject to subdivision (f) of Section 14184.102 and paragraph (5) of this subdivision, the department may require each Medi-Cal managed care plan to operate, or continue to operate, a D-SNP in accordance with the CalAIM Terms and Conditions, and in accordance with federal requirements for each D-SNP to have an executed contract with the department, referred to as an SMAC. The requirements described in this paragraph shall not be applicable to a subcontracted delegate health plan.

(2) In non-Coordinated Care Initiative counties, beginning no later than contract year 2025, the department shall only contract with a proposed D-SNP that is affiliated with a Medi-Cal managed care plan or subcontracted delegate health plan, or was contracted with the department for a D-SNP in the proposed D-SNP service area in the contract year that immediately precedes the contract year in which this paragraph is implemented with respect to an individual county.

(3) In non-Coordinated Care Initiative counties, beginning no later than contract year 2026, a dual eligible beneficiary shall be assigned to a Medi-Cal managed care plan or a subcontracted delegate health plan that is affiliated with the Medicare Advantage plan, including a D-SNP, in which the dual eligible beneficiary is enrolled. The department may approve exceptions to the requirement described in this subparagraph when it determines necessary to support beneficiary enrollment choice.

(4) In non-Coordinated Care Initiative counties, beginning no later than contract year 2025, dual eligible beneficiaries not already enrolled in a D-SNP, in the contract year that immediately precedes the contract year in which this paragraph is implemented with respect to an individual county, may only enroll in a D-SNP that is affiliated with a Medi-Cal managed care plan, or a subcontracted delegate health plan, in the beneficiary’s service area. Beginning no later than contract year 2025, D-SNPs that are not affiliated with a Medi-Cal managed care plan or a subcontracted delegate health plan shall not accept new enrollment of dual eligible beneficiaries.

(5) The department shall conduct a feasibility study of D-SNPs, in specific non-Coordinated Care Initiative counties as determined by the department, to be completed no later than July 1, 2022. As a result of the study findings, or evidence provided by a Medi-Cal managed care plan of the potential for significant financial losses that may be incurred by a Medi-Cal managed care plan as a result of operating a D-SNP, and evidence provided by a Medi-Cal managed care plan that the plan has made a good faith effort but is not able to develop a partnership with a D-SNP for coordinated care across Medicare and Medi-Cal, the department may provide, in its sole discretion, an exemption from the requirements in paragraph (1) of this subdivision on an individual plan basis for a period of three years. The department may renew this exemption for successive three-year periods based on study findings or evidence of potential losses, and evidence of a good faith effort, as specified in this paragraph.

(d) To ensure dual eligible beneficiaries are fully informed regarding aligned enrollment, the department or the Med-Cal managed care plan, as applicable, shall provide informing notices to affected beneficiaries regarding Medi-Cal plan enrollment changes related to aligned enrollment. The notices shall be developed in consultation with consumer advocates.

(e) Beginning in contract year 2023, the department shall include requirements for network adequacy, aligned networks, and continuity of care in the SMAC. The requirements shall be developed in consultation with affected stakeholders.

(f) The department shall contract with public or private entities in assisting dual eligible beneficiaries in understanding their health care coverage options, overcoming access to care barriers, and addressing eligibility and enrollment barriers.

(g) The department shall convene a workgroup including plans, providers, and consumer stakeholders to discuss transition to a statewide Managed Long-Term Services and Supports and D-SNP structure.

(h) For purposes of this section, the following definitions apply:

(1) “Coordinated Care Initiative counties” means the Counties of Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara.

(2) “Dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.) or Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or both, and is eligible for medical assistance under the Medi-Cal State Plan. For purposes of this section, “dual eligible beneficiary” shall include both “full-benefit dual eligible beneficiaries” and “partial-benefit dual eligible beneficiaries,” as those terms are defined in this subdivision.

(3) “Full-benefit dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.), Medicare Part B (42 U.S.C. Sec. 1395j et seq.), and Medicare Part D (42 U.S.C. Sec. 1395w-101), and is eligible for medical assistance under the Medi-Cal State Plan.

(4) “Medicare Advantage Dual Special Needs Plan” or “D-SNP” shall have the same meaning as set forth in Section 1395w-28(b)(6) of Title 42 of the United States Code.

(5) “Partial-benefit dual eligible beneficiary” means an individual 21 years of age or older who is enrolled for benefits under Medicare Part A (42 U.S.C. Sec. 1395c et seq.), but not Medicare Part B (42 U.S.C. Sec. 1395j et seq.), or who is enrolled for Medicare Part B (42 U.S.C. Sec. 1395j et seq.), but not Medicare Part A (42 U.S.C. Sec. 1395c et seq.), and is eligible medical assistance under the Medi-Cal State Plan.

(6) “Subcontracted delegate health plan” means a health care service plan that is a subcontractor of a Medi-Cal managed care plan that the department determines to have assumed the entire financial risk for all Medi-Cal services provided to a dual eligible beneficiary that are covered under the applicable comprehensive risk contract of the Medi-Cal managed care plan.

(7) “Subcontractor” shall have the same meaning as set forth in Section 438.2 of Title 42 of the Code of Federal Regulations.

(i) For purposes of this section, “Medi-Cal managed care plan” shall not include a managed care plan contract with the AIDS Healthcare Foundation.