MediConnect - Dual Eligible integrated care program

Program Location: 
Los Angeles, CA
Payer Type: 

California signed a Memorandum of Understanding with CMS on 3/27/2013. The state Medi-Cal program and the federal Medicare program are partnering to launch a three-year project to promote coordinated health care delivery to seniors and people with disabilities who are dually eligible for both of the public health insurance programs, “dual eligible beneficiaries. ”The program will be called Cal MediConnect. It will be implemented no sooner than April 2014 in eight counties: Alameda, San Mateo, Santa Clara, Los Angeles, Orange, San Diego, Riverside and San Bernardino. 

The Cal MediConnect program aims to improve care coordination for dual eligible beneficiaries and drive high quality care that helps people stay health and in their homes for as long as possible. Additionally, shifting services out of institutional settings and into the home and community will help create a person-centered health care system that is also sustainable. The Cal MediConnect program is part of California’s larger Coordinated Care Initiative (CCI). Building on many years of stakeholder discussions, the CCI was enacted in July 2012 through SB 1008 (Chapter 33, Statutes of 2012) and SB 1036 (Chapter 45, Statutes of 2012). 

Participating Plans will offer person-centered medical homes with interdisciplinary care teams, which will be built around the enrollee. Decisions will be made collaboratively and with respect to the individual’s right to direct care. ICTs may include the designated primary physician, nurse case manager, social worker, patient navigator, pharmacist, and behavioral health service providers. The beneficiary can choose to limit or disallow altogether the role of IHSS providers, family members, and other caregivers on the care team.


Rollout of this program has undergone delays as well as pushback from providers and patients. California instituted a passive enrollment, meaning that dual eligible beneficiaries must opt out of MediConnect if they wish to maintain their existing FFS providers. Participation in the demonstration requires several decisions for patients, which has led to consumer frustration and confusion. 

Unfortunately, due to these problems with communication and rollout, the demonstration has, as least initially, failed to meet expectations. As of June 1, 2015, only 122,846 dually eligible individuals have enrolled due to a high opt out rate and consumer cancellation to plans within the first few months of enrollment. Click here to read more about the challenges to implementation as well as the state's proposed solutions to get demonstration back on track. 

Payment Model: 

For each calendar year of the Demonstration, before rates are offered to Prime Contractor Plans, CMS shall share with the State the amount of the Medicare portion of the capitated rate, as well as collaborate to establish the data and documentation needed to assure that the Medicaid portion of the capitation rate is consistent with all applicable Federal requirements. CMS will make separate payments to the Prime Contractor Plans for the Medicare A/B and Part D components of the rate. Detailed payment information can be found in Appendix 6 in the approved CMS contract. 

Improved Health: 
  • For one measure reported (initiation of alcohol and other drug dependence treatment), the majority of plans performed better than the national Medicare Advantage benchmark value (32.3 percent)
  • Four out of nine plans performed better than the benchmark value for providing medical attention for nephropathy (95.5 percent) and blood pressure control (60.9 percent)

Last updated April 2019
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