Dual Eligible Demonstration Project

According to the Medi-Cal Website, California’s Medi-Cal program and the federal Medicare program are partnering to launch a three-year demonstration beginning in 2013 that would promote coordinated health care delivery to seniors and people with disabilities who are dually eligible for both programs.

The duals demonstration — now called the Cal MediConnect Program — aims to create a seamless service delivery experience for dual eligible beneficiaries, with the ultimate goals of improved care quality, better health and a more efficient delivery system.

The Cal MediConnect program will be implemented no sooner than January 1, 2014 in eight counties: Alameda, San Mateo, Santa Clara, Los Angeles, Orange, San Diego, Riverside and San Bernardino.”

The following reimbursement issues should be considered under the dual eligible demonstration project:

  • Inpatient hospital utilization is expected to decrease if in fact the patient’s health care is more tightly managed.
  • For patients placed in the new M+C program, there will no longer be crossover claims relating to unpaid deductibles and coinsurance to include on the cost report, resulting in lower reimbursed bad debts through the cost report settlement.
  • The appeal efforts to exclude Medicare Managed Care SSI from the DSH will need to rethink strategy, as the dual eligible in the Medicare Managed Care population are the most likely to qualify for SSI, and therefore result in increased DSH payments.
  • The empirically justified portion of the DSH formula will decrease as that formulary is only applied to fee for service Medicare payments.
  • Medicare Medical education payments should continue as there are add-on payments for both IME and DGME for Medicare Managed Care patients.
  • Hospitals with paramedical education programs will have higher Allied Health add-on payments due to the shift in Medicare volume from fee for service (DRG) to Managed Care.

PFC can help. If you have any questions, e-mail Joseph Fass (310-874-0829) or Susan Starr (925-377-5181).

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