Below are the definitions of commonly-used terms in L.A. Care’s New CCI Glossary:
A member’s or provider’s request for review of L.A. Care’s coverage or payment determination, or a request for review of an adverse determination based on an administrative policy.
A person who is eligible for both Medicare and Medicaid (Medi-Cal) and as such, is also eligible for enrollment in Cal MediConnect, but who has not yet enrolled into L.A. Care for Cal MediConnect (i.e., is not yet an L.A. Care Cal MediConnect member). Often, we use the terms Eligible Beneficiary or Dual Eligible Beneficiary.
CA Department of Aging (CDA)
California State Agency for administering programs that serve older adults, adults with disabilities, family caregivers, and residents in long-term care facilities throughout the State. The Department administers funds allocated under the Federal Older Americans Act, the Older Californians Act, and through the Medi-Cal program. CDA certifies CBAS centers for participation in the Medi-Cal Program and provides administrative oversight for the MSSP waiver.
CA Department of Social Services (CDSS)
California state agency for overseeing and providing social services, including the In Home Support Services (IHSS) program.
Cal MediConnect (CMC)
A voluntary joint federal and state program that is designed to coordinate medical, mental and substance abuse care, long-term care, home and community based services, and assistance with social services under one plan for Beneficiaries. Cal MediConnect should be referred to as “formerly known by the Duals Demonstration Pilot” upon first use in written communications, and in all following instances as Cal MediConnect. LA Care’s offering is called “LA Care Cal MediConnect Plan.”
Cal MediConnect Health Plan
The Health Plans selected to participate in the Cal MediConnect program. These plans are also referred to as Participating Plans. The Cal MediConnect plans in Los Angeles include L.A. Care Health Plan, Health Net, Blue Shield of California Promise Health Plan, CareMore and Molina Healthcare.
Care Plan Option Services (CPOs)
Formerly known as “in lieu of benefits;” non-medical services that are not covered by Medicare or Medi-Cal that a Cal MediConnect Health Plan may offer to a Cal MediConnect member in order to help keep people living independently in their homes and communities. CPOs can range from nutritional counseling to installing ramps or grab bars in a Member's home.
Clinical Care Management
A set of services provided by a Clinical Care Manager that comprise intensive monitoring, follow-up, care coordination, and clinical management of high-risk Enrollees. (MOU definition)
Clinical Care Manager
A licensed registered nurse or other individual licensed to provide Clinical Care Management. (MOU definition) See RN, Care Manager.
Centers for Medicare and Medicaid Services, a federal agency responsible for providing oversight to the federal and state Medicare and Medicaid programs, and the Cal MediConnect program.
Community-Based Adult Services (CBAS)
An LTSS benefit, CBAS is an outpatient, facility-based service program that delivers skilled nursing care, social services, therapies, personal care, family and caregiver training and support, meals, and transportation in order to help individuals live independently in their homes as long as possible.
Complex Case Management (CCM)
A level of case management services provided to Members whose complexity of condition is severe, whose level of management required is intensive, and for whom the amount of resources required to achieve optimal health status is extensive. Approximately 5% of the CMC member population is projected to be defined as Complex and to require Complex Case Management.
The “three-way Contract” refers to the participation agreement that CMS and DHCS has with a Prime Contractor Plan for the terms and conditions pursuant to which a Participating Plan can participate in Cal MediConnect. We currently do not have a signed three-way contract in place.
A process used by a person or team to help beneficiaries gaining access to necessary Medicare and Medicaid services, including medical care, behavioral health services, MLTSS, and social services.
Coordinated Care Initiative (CCI)
An initiative by California, the CCI changes the way Seniors and People with Disabilities receive health care coverage and services in California. The first part of the CCI includes the transition of most people on Medi-Cal, including those also eligible for Medicare, to a Medi-Cal health plan to access Medi-Cal benefits, including MLTSS. The second major component is the voluntary Cal MediConnect program. In conjunction with the CCI, Beneficiaries will be subject to Passive Enrollment.
The full range of mental health and physical health services currently covered by Medicare and Medi-Cal that will be offered by the Participating Plans under CMC.
The Department of Health Care Services is the California state agency that administers the Medi-Cal program and the State’s components of the Cal MediConnect program.
The Department of Managed Health Care is the California state agency charged with overseeing HMOs licensed under the Knox-Keene Act.
The Los Angeles County Department of Mental Health (DMH) is the largest county mental health department in the country. DMH will be providing behavioral health services for Cal MediConnect Members.
The Los Angeles County Department of Public Health (DPH) protects health, prevents disease, and promotes the health and well-being for all persons in Los Angeles County. DPH provides substance abuse care for Cal MediConnect Members.
The Department of Public Social Services (DPSS) authorizes IHSS worker hours for Cal MediConnect Members.
Dual Eligible Beneficiaries
People eligible for both Medicare and Medi-Cal; also known as Medi-Medis.
Duals Demonstration Pilot (DDP)
Former name of Cal MediConnect.
The State’s term for any Dual Eligible Beneficiary who is enrolled in a Participating Plan. L.A. Care uses the term Member.
The State’s term for materials designed to communicate to Enrollees Health Plan benefits, policies, processes and/or enrollee rights. This includes pre-enrollment, post-enrollment, and operational materials. These are often referred to as the 90, 60, and 30 day notices for pre-enrollment materials, and the new Member welcome packet for post enrollment materials.
An official meeting with a judge about a Medi-Cal appeal or grievance. Members must ask for a fair hearing within 90 days of the date that their Medi-Cal benefits were denied, reduced, or stopped. (MOU definition) Also called State Fair Hearing.
A way for Members to write or tell the Health Plan about their unhappiness with their doctor or delivery of a covered benefit or service, or the Health Plan’s administration of the CMC.
Non-licensed staff assigned to each Member, they help Members navigate through the health care system by coordinating and facilitating access to both covered and noncovered services to achieve optimal health outcomes. Health Navigators are trained on Medicare and Medicaid benefits and educate Members and Members’ families on various topics to ensure the Member is making active choices on how care is shaped and delivered according to their needs.
Home and Community Based Services (HCBS)
A Medi-Cal benefit; services and supports provided to individuals in their own home or other community residential settings that promote their independence, inclusion, and productivity.
Individualized Care Plan (ICP)
The plan of care developed by a CMC Member and the Member’s Interdisciplinary Care Team (ICT). Also called Care Plan.
In-Home Supportive Services (IHSS)
A Medi-Cal benefit; the IHSS program provides in-home care for people who cannot safely remain in their own homes without assistance. To qualify for IHSS, a recipient must be aged, blind, or disabled and, in most cases, have income below the level to qualify for the Supplemental Security Income/State Supplementary Program.
In Lieu of Benefits
Now known as Care Plan Option services (CPOs) (see Care Plan Option services definition)
Interdisciplinary Care Team (ICT)
A team that includes the Member and others of the Member’s choosing such as the primary care doctor, care coordinator, social worker, IHSS worker, and other providers, caregivers, or social supports such as family that work with the Member to develop, implement and maintain his/her ICP. ICT participation is at the discretion of the Member.
Long-Term Services and Supports (LTSS)
A Medi-Cal benefit; LTSS include a range of home and community-based services such as IHSS, CBAS, and MSSP in addition to care in nursing facility services when needed. Please see LTSS section below for additional definitions and information.
Managed Long-Term Services and Supports (MLTSS)
The transition of Long-Term Services and Supports to a Health Plan Benefit.
The program established under authority of Title XIX of the Social Security Act that covers medical assistance for low-income people who meet specific eligibility criteria.
California’s Medicaid program.
Medically Necessary Services
Services must be provided in a way that provides all protections to the Enrollee provided by Medicare and Medi-Cal. Per Medicare, services must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, or otherwise medically necessary under 42 USC 1395y. In accordance with Medicaid law and regulations, and per Medi-Cal, medical necessity means reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness, or injury. (MOU definition). When administering the CMC program, the definition most lenient for the Member is used.
The federal health insurance program established under Title XVIII of the Social Security Act to provide health care for people aged 65 and older, people under the age of 65 with certain disabilities, and people with end stage renal disease (ESRD); permanent kidney failure requiring dialysis or a kidney transplant.
• Medicare Part A provides coverage of inpatient hospital services and services of other institutional providers, such as skilled nursing facilities and home health agencies.
• Medicare Part B provides supplementary medical insurance that covers physician services, outpatient services, some home health care, durable medical equipment, and laboratory services and supplies, generally for the diagnosis and treatment of illness or injury.
• Medicare Part C provides Medicare beneficiaries with the option of receiving Part A and Part B services through a private Health Plan.
• Medicare Part D provides coverage for most pharmaceuticals.
The State’s term for individuals who are entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medi-Cal benefits and no other comprehensive private or public health coverage. These individuals are also referred to as Duals, Dual Eligible Beneficiaries, or Medi-Medis.
A Beneficiary who has joined L.A. Care’s Cal MediConnect.
Memorandum of Understanding (MOU)
The document that details the principles under which CMS and DHCS plan to implement and operate CMC. It also outlines the activities CMS and DHCS plan to conduct in preparation for implementation of the Contract.
Model of Care
The term used by CMS to describe the process and structure used to manage a population, including the Health Plan’s staffing, provider network, care management program, and quality improvement program. Each Plan is required to submit a Model of Care to CMS and DHCS for approval. There are 11 elements required by CMS, and a 12th element required by DHCS.
Multi-Purpose Senior Services Program (MSSP)
This program provides both social and health care management services to help Medi-Cal recipients aged 65 or older who meet the eligibility criteria for a skilled nursing facility remain in their homes. In addition to the care management service, each MSSP site has funds reserved for purchasing services necessary to maintain a person in the community after all other public or private program options have been exhausted.
A Beneficiary completing the State’s enrollment form by choosing not to join Cal MediConnect.
Benefits or services that are covered by both Medicare and Medi-Cal. The MOU indicates that the Contract will provide more specific instruction on handling some aspects of Overlapping Services. In year one of the Contract, the appeals process for Overlapping Services allows the Member to select the appeals path (Medicare appeal process or Medi-Cal appeals process), with the option of a State Fair Hearing in all Overlapping Services cases.
A Prime Contractor Plan, or a Subcontracted Plan, contracted to provide and accountable for providing coordinated care through Cal MediConnect to Members. Participating Plans in Los Angeles include L.A. Care Health Plan, Health Net, Blue Shield of California Promise Health Plan, CareMore and Kaiser Permanente.
An enrollment process that will be used for Cal MediConnect. Under this process, eligible Beneficiaries will be enrolled automatically into Cal MediConnect unless they voluntarily choose to “Opt Out.” Eligible Beneficiaries will receive multiple notices about their enrollment options (during a 90-day advance notification period), including their choice to opt out of Cal MediConnect. If Beneficiaries do not make a choice to Opt Out of Cal MediConnect, they will be passively assigned to one of the Cal MediConnect Health Plans in their county.
Prime Contractor Plan
Health plans selected by DHCS to provide the Cal MediConnect program in designated counties. L.A. Care and Health Net are the Prime Contractor Plans for Los Angeles County.
Program of All-Inclusive Care for the Elderly (PACE)
A comprehensive service delivery and financing model that integrates medical and LTSS under dual capitation agreements with Medicare and Medicaid. The PACE program is limited to individuals age 55 and over who meet the skilled nursing facility level of care criteria and reside in a PACE service area. PACE enrollees are excluded from the Passive Enrollment process for Cal MediConnect.
Before the signing of the Contract, DHCS and CMS must agree that a Participating Plan has demonstrated readiness to implement the approved Model of Care and all CMS and DHCS requirements. At a minimum, each Readiness Review will include a desk review of documentation submitted electronically, followed by an onsite visit to assess functional and systems capability. CMS has contracted with NORC to perform the Readiness Reviews.
RN, Care Manager
L.A. Care defines this role as the Registered Nurse directly responsible for the delivery of care management services to Members; Consistently assess, plan, facilitate and advocate for Members throughout the continuum of care, consistent with DHCS and CMS regulatory requirements, CMS MAPD structure and process measures, accreditations standards, standards of practice and L.A. Care’s Policies and Procedures. See Clinical Care Manager for MOU definition of same role.
Skilled Nursing Facilities (SNFs)
SNFs encompass nursing homes and rehabilitation facilities and provide nursing, rehabilitative, and medical care.
The Department of Health Care Services (DHCS).
The benefits being required by DHCS for Cal MediConnect that are in addition to the standard Medicare and Medi-Cal benefits (i.e., dental, vision, transportation).
Transitions of Care
Changes in patient care settings, such as a move from inpatient hospital to Skilled Nursing Facility, or from the home to an Emergency Room. Transitions may be planned or unplanned.