Key Takeaways
- Via CalAIM, Medicare Medi-Cal Plans (often known as EAE D-SNPs) maintain the promise of higher care coordination for dually eligible enrollees.
- To achieve success, these plans will need to have supplier networks that enable individuals to entry the suppliers they know, however a RAND report highlights noteworthy gaps.
- A number of methods – together with leveraging knowledge and focused clinician outreach – might help managed care organizations develop optimum supplier networks.
About 1.7 million Californians are enrolled in each Medi-Cal and Medicare, however these two separate techniques will not be at all times aligned. This lack of alignment could make it troublesome for enrollees to get the care they want once they want it. Via the state’s CalAIM (California Advancing and Innovating Medi-Cal) initiative, California is rolling out a program particularly for these dually eligible enrollees to allow them to obtain Medi-Cal and Medicare advantages via one managed care group. The objective of those new plans, recognized in California as Medicare Medi-Cal Plans (and technically as Solely Aligned Enrollment Twin Eligible Particular Wants Plans – or EAE D-SNPs), is to make it simpler for individuals to get the care and companies they want whereas enhancing coordination throughout each applications.
Some of the efficient methods to make these new plans extra interesting is to make sure enrollees can entry the well being care suppliers with whom they’re most acquainted. Presently, California’s Division of Well being Care Providers recommends that these plans have an overlap of not less than 90% with present Medi-Cal supplier networks. However for these plans to be broadly interesting, further clinicians who present companies to dually eligible enrollees via Medicare can even have to be included.
A 2025 RAND report compares present Medi-Cal supplier networks with the suppliers serving over 700,000 dually eligible Californians who’ve conventional fee-for-service (FFS) Medicare. The report highlights a number of noteworthy gaps that plans ought to take note of as they develop their networks. RAND’s key findings embody:
- Variations in networks. Solely 60% of clinicians offering visits to FFS Medicare dually eligible enrollees have been additionally present in Medi-Cal managed care supplier listings.
- Vast variation. Whereas 65% of major care physicians seen by FFS Medicare dually eligible enrollees have been included in Medi-Cal lists, the speed was a lot decrease for specialists like psychiatrists (47%).
- Gaps in key settings. Lower than half (47%) of clinicians offering visits to FFS Medicare dually eligible enrollees in expert nursing services have been listed within the Medi-Cal managed care supplier listings.
- Concentrated care. A small subset of clinicians (18%) offered 80% of all visits for FFS Medicare dually eligible enrollees, that means a small group of clinicians is offering a disproportionate quantity of care.
Wanting Forward: What can managed care plans and policymakers do to make sure enrollees in each Medi-Cal and Medicare can proceed seeing their common suppliers?
As these new plans proceed to roll out, the RAND report identifies a number of alternatives for managed care organizations (MCOs) and policymakers to develop optimum supplier networks that guarantee continuity and entry to care.
| Alternative | MCOs | Policymakers |
|---|---|---|
| Leverage knowledge | Use knowledge and market insights to determine and deal with gaps in supplier networks. | Analyze care patterns amongst several types of enrollees to make sure supplier networks are aware of all enrollees. |
| Goal outreach | Interact extra clinicians for Medicare Medi-Cal Plan contracting. | Look at and deal with potential care disruptions amongst specialties and areas through which care is concentrated amongst fewer clinicians. |
| Develop sources | Present clearer details about suppliers on consumer-facing supplies. | Develop benchmarks for community entry. |
| Monitor implementation | Monitor each enrollment and disenrollment patterns. | Monitor whether or not plans are adapting their networks to satisfy the wants of all Californians who may gain advantage from these plans. |
Learn the total report: Constructing Supplier Networks for Enrollees in Each Medicare and Medi-Cal, CHCF, January 2025.