Provider Network Alignment: A Critical Factor for Success in Medicare Medi-Cal Plans – Policy at a Glance

About 1.7 million Californians are enrolled in each Medi-Cal and Medicare, however these two separate methods are usually not at all times aligned. This lack of alignment could make it troublesome for enrollees to get the care they want once they want it. By 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 purpose of those new plans, identified 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 providers they want whereas bettering coordination throughout each packages.

Probably the most 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. At the moment, California’s Division of Well being Care Companies recommends that these plans have an overlap of no less than 90% with current Medi-Cal supplier networks. However for these plans to be broadly interesting, extra clinicians who present providers to dually eligible enrollees via Medicare will even have to be included.

A 2025 RAND report compares current 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 had been additionally present in Medi-Cal managed care supplier listings.
• Extensive variation. Whereas 65% of major care physicians seen by FFS Medicare dually eligible enrollees had 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 had been listed within the Medi-Cal managed care supplier listings.
• Concentrated care. A small subset of clinicians (18%) supplied 80% of all visits for FFS Medicare dually eligible enrollees, that means a small group of clinicians is offering a disproportionate quantity of care.

Trying 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.

Learn the complete report: Constructing Supplier Networks for Enrollees in Each Medicare and Medi-Cal, CHCF, January 2025.