by Jay Luxenberg, MD

As California moves forward with plans to enroll all dual-eligible (those with both Medicare and MediCal insurance) into managed care, a milestone was reached with the announcement on April 4, 2012 of the first 4 counties that will serve as the pilot for statewide implementation. Of course, since the four counties chosen (Los Angeles, Orange, San Diego and San Mateo counties) house approximately 50% of all California dual eligibles, perhaps the term “pilot” is misleading. Also announced were an additional 6 counties that may be implemented at the same starting date (January 1, 2013) if authorized by legislation - San Bernardino, Riverside, Santa Clara, Contra Costa, Alameda and Sacramento.

What does this mean to me, you might ask? The intent is to mandatorily enroll all eligible persons in one or two plans per county, similar to what has already been done for seniors and persons with disability that have MediCal but not Medicare. That process did not go smoothly, so hope is that lessons have been learned prior to starting enrollment of the much larger group of dual eligibles. Nursing home care (now paid by the state) will be the responsibility of the managed care organization. This will potentially alter the primary care of many current nursing home residents whose providers are not contracted with the chosen managed care organizations. Although PACE programs will still be an option for duals, how this will interact with the mandatory enrollment and proposed lock-in periods is still unclear. Going forward, how nursing homes will interact with the managed care companies also remains to be defined. Of course, optimistically this process offers the potential for innovation and improved coordination of care.

I know this sounds crazy, but so far I have found the state’s Twitter feed to be the best source of information as this process goes forward - https://twitter.com/#!/CalDuals. There are several workgroups where stakeholders will have a say in the process of implementation – info is here.

Of course, there will be plenty of opportunity to learn more and discuss the implications at our upcoming CALTCM Meeting May 11-12! CALTCM’s Policy & Professional Services Committee is working on a Position Paper on the state’s Dual Eligible program, so you can look forward to continued information and advocacy from the premier long term care professional organization in the state.