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New Plan Offered to Dual Eligible Medicare-Medi-Cal Patients
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Sue U. Malone
You
may already have heard of HPSM, the Medi-Cal
managed health care plan in this county, sought, and recently received,
authorization from the Centers for Medicare and Medicaid (CMS) to
implement a Medicare Advantage Special Needs Plan for their Medi-Medi
members (known as dual-eligibles) who are enrolled in both the Medi-Cal
and Medicare programs. There are approximately 10,000 dual-eligibles in
the county. The HPSM CareAdvantage program is only authorized to provide
these benefits to the Medi-Medi population. At first we were
concerned that the plan, set up as a “passive” or “opt-out”
patient election, might disrupt continuity of care and potentially sever
long-standing physician-patient relationships. However, having met with
Mia Altman, the new interim executive director of the HPSM, and Wayne
Pan, the medical director, as well as with the director of finance and
the director of operations, we felt that the program may actually
benefit physicians and patients. CareAdvantage will
have a separate network of doctors. To ensure continuity of care, the
CareAdvantage program will contract with physicians for the
CareAdvantage network without requiring physicians to participate in the
Medi-Cal program. All providers in the new network will be
enrolled in the HPSM/CareAdvantage network. In addition, as an incentive
to doctor participation in the new program, the HPSM will reimburse
doctors at 90 percent of the Medicare allowable rate, rather than 80
percent as payment in full. Under the plan,
patients will be relieved of the burden of deciding what Part D Drug
Plan (PDP) to select and will not be responsible for premiums or
deductibles called for under the regular Part D program, though there
will be a small $1 to $5 co-payment for each prescription. I hope you will
consider joining this network. HPSM will be sending a mailing to all
Medi-Medi patients in October informing them of this new plan. This is a
passive (opt-out) enrollment program. A patient can opt-out of
CareAdvantage and choose the traditional Medicare (fee-for-service
Medicare), or another Medicare Advantage managed care plan. If a patient
selects the fee-for-service Medicare program, he/she will be required to
select or be assigned a Part D drug plan. The CareAdvantage program goes
into effect on January 1; however, patients must make their election by
October 31. After that, Medi-Medi members will still be able to opt-out
of CareAdvantage and select
another Medicare Advantage managed care plan or the traditional Medicare
program on a monthly basis.
We are informed that
the HPSM will be working with its Medi-Medi members to identify their
current physicians for Medicare services. The plan will then contact
these physicians to encourage them to contract with the new Care
Advantage program. There will be a six-month transition period (from
January through June 2006) during which noncontract physicians will
continue to be paid by the plan at current Medicare fee-for-service
rates and will be asked to sign contracts. As mentioned earlier, members
will be able to opt-out if they wish to stay with their provider and the
physician does not elect to join the HPSM CareAdvantage network. You may be aware that
in recent years HPSM has been faced with severe financial challenges.
The other programs that HPSM administers have helped them offset these
challenges posed by lack of adequate funding in the Medi-Cal managed
care program. This new program also will help offset these continuing
deficits in the Medi-Cal program. Based on the
complexity of the new Part D drug program, we feel that the
CareAdvantage program will work well for Medi-Medi patients and will aid
physicians in retaining their Medi-Medi patients. Call HPSM to sign up
for the CareAdvtange network or ask questions about the program. The
HPSM Provider Relations Department can be reached at 650-616-2106.
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