Medicare Advantage Information for Dual Eligible Beneficiaries
Return to Integrated Care for Dual Eligible Beneficiaries
Some people qualify for both Medicare and Medi-Cal and are “dual eligible” or Medi Medi beneficiaries. When an individual has both Medicare Parts A and B, Medicare is the primary insurance and pays for most medical care. Medi-Cal is the secondary insurance. It pays for costs not covered by Medicare and provides additional benefits not covered by Medicare.
Like all Medicare beneficiaries, dual eligible beneficiaries can choose whether to receive care through Original Medicare, or enroll in a Medicare Advantage (MA) plan, sometimes called “Part C” or “MA Plans.” In California there are several types of MA plans, and plan options vary by county.
Some plans provide integrated care, across both Medicare and Medi-Cal benefits. The My Care My Choice website provides information about integrated care options in each county, and local HICAP organizations can also provide assistance.
As described below, some MA options for dual eligibles in California will be changing effective January 1, 2023. Many of these changes will be automatic, so no action is needed by the member. MA plans will notify any members impacted by these changes.
An estimated 43 percent of the 1.5 million dual eligible beneficiaries in California are enrolled in some type of Medicare Advantage. Of those, over 200,000 are in “Regular” MA plans; approximately 140,000 are in “look-alike” plans; 130,000 are in true Dual Eligible Special Needs Plans (D SNPs); and 140,000 are in Cal MediConnect or other integrated plans.
Medicare Medi-Cal Plans (MMPs or Medi-Medi Plans) (Starting January 1, 2023)
Medicare Medi-Cal Plans (MMPs or Medi-Medi Plans) is the California-specific program name for Exclusively Aligned Enrollment Dual Eligible Special Needs Plans (EAE D-SNPs). These are health plans that provide integrated Medicare and Medi-Cal benefits to dually eligible beneficiaries. Members of Cal MediConnect plans (in Coordinated Care Initiative counties) will automatically transition to MMPs on January 1, 2023, as part of the CalAIM Initiative to continue providing integrated and coordinated care to dual eligible beneficiaries.
These plans will meet integrated D-SNP care coordination requirements, will have integrated member materials, and will have membership limited to dually eligible individuals who are also enrolled in the Medi-Cal managed care plan affiliated with the D-SNP. This aligned enrollment provides more integrated and coordinated care than other D-SNPs, where members may not be in a Medi-Cal plan that aligns with their Medicare plan. When dual eligible beneficiaries choose a Medicare plan that is an MMP, they are automatically enrolled in the Medi-Cal plan that aligns with their Medicare plan, so there is one organization coordinating care across both sets of benefits.
DHCS strongly supports integrated care options for dual eligible beneficiaries, since it improves care coordination, can lead to better health outcomes, and provides a more efficient delivery system for beneficiaries and providers. MMPs will help beneficiaries with all of their health care needs and will coordinate benefits and care, including medical and home and community-based services, durable medical equipment, and prescriptions. This coordination will be similar to what is now done in Cal MediConnect plans.
“Regular” Medicare Advantage Plans (for all Medicare beneficiaries)
Many MA) plans serve both dual eligible and Medicare only members. Premiums, out-of-pocket limits, cost sharing, extra benefits offered, and prior authorization vary by plan, although cost-sharing for duals is limited. Most MA plans also offer prescription drug coverage. “Regular” MA plans serve both dual eligible and Medicare only members and are not required to have written agreements with state Medicaid agencies, such as DHCS, for benefit and care coordination for dual eligible beneficiaries.
MA Dual Eligible Special Needs Plans (D-SNPs)
D-SNPs are a type of MA plan that provide specialized care and wrap-around services for dual eligible beneficiaries. Enrollment is limited to dual eligible beneficiaries. D-SNPs must have a signed State Medicaid Agency Contract (SMAC) with DHCS, which establishes care coordination and Medicare-Medi-Cal benefit coordination requirements for the plan. Based on state law, DHCS determines whether to contract with specific D-SNPs in each county.
MA D-SNP Look-alike Plans
D-SNP “look-alike” plans are MA plans that are marketed to and have membership of at least 80 percent dual eligible beneficiaries, but do not have the care coordination and wrap-around services that true D-SNPs provide. These plans often have marketing names that sound like D-SNPs, using the terms “coordinated” or “dual.” Look-alike plans may be unattractive to non-dual eligible beneficiaries because they often have higher cost-sharing requirements – which only dual eligible beneficiaries are not required to pay.
Because look-alike plans target dual eligible individuals but are not subject to integration requirements that benefit duals, the federal Centers for Medicare & Medicaid Services (CMS) issued regulations in 2020 that require MA organizations to discontinue D-SNP look-alike plan contracts effective January 1, 2023. The 2020 federal regulations also provide an option for those MA organizations to transition their look-alike members to other MA plans offered by the same organization, either true D-SNPs or regular MA plans with $0 premium. MA plans will work with CMS in 2022 to implement this membership transition. The most recent guidance from CMS to MA organizations on this transition is here. The transition is designed to provide continuity of care and cost-sharing protections for dual eligible beneficiaries, as well as provide better care options for people currently enrolled in a look-alike plan.
MA organizations with look-alike plans are required to send notices in fall 2022 to their members with information about the plan transition. A summary list of D-SNP Look-Alike Transition and Receiving Plans in California, effective January 1, 2023, is available here: [CY CA D-SNP Look-alike Transition Estimates]
Cal MediConnect Plans
In 2014 DHCS and CMS partnered to launch Cal MediConnect, a demonstration to promote coordinated health care delivery for dual eligible beneficiaries. This plan aims to create a seamless service delivery experience for dual eligible beneficiaries, with the ultimate goals of improved care coordination, better health outcomes, and a more efficient delivery system.
Cal MediConnect plans are available in the following seven counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara. New enrollment in Cal MediConnect is available through the end of 2022. Cal MediConnect beneficiaries will automatically transition within their existing MA organization to a D-SNP and matching Medi-Cal plan on January 1, 2023. Beneficiaries transitioning from Cal MediConnect will continue to have access to a complete provider network through their matching D-SNP and Medi-Cal plan, which will include similar providers they see today, or their plan will help them find a new doctor they like. For more information about the future of Cal MediConnect, please visit The Future of Cal MediConnect webpage.
Other Integrated Plan Models
Program of All-Inclusive Care for the Elderly (PACE): PACE covers Medicare and Medi-Cal benefits, including prescription drugs. It will coordinate healthcare, homecare, transportation, and dental care. To find out if PACE is available in your area, and to enroll, please go to the CalPACE web page.
SCAN Connections at Home is a Medicare Advantage Special Needs Plan that covers Medicare and Medi-Cal benefits, including prescription drugs. It will coordinate all healthcare, homecare, transportation, and related benefits. To find out if SCAN Connections at Home is available in your area, and to enroll, please go to Scan Health Plan web page.
