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 both Medi-Cal and Medicare, but these two separate systems are not always aligned. This lack of alignment can make it difficult for enrollees to get the care they need when they need it. Through the state’s CalAIM (California Advancing and Innovating Medi-Cal) initiative, California is rolling out a program specifically for these dually eligible enrollees so they can receive Medi-Cal and Medicare benefits through one managed care organization. The goal of these new plans, known in California as Medicare Medi-Cal Plans (and technically as Exclusively Aligned Enrollment Dual Eligible Special Needs Plans – or EAE D-SNPs), is to make it easier for people to get the care and services they need while improving coordination across both programs.

One of the most effective ways to make these new plans more appealing is to ensure enrollees can access the health care providers with whom they are most familiar. Currently, California’s Department of Health Care Services recommends that these plans have an overlap of at least 90% with existing Medi-Cal provider networks. But for these plans to be broadly appealing, additional clinicians who provide services to dually eligible enrollees through Medicare will also need to be included.

A 2025 RAND report compares existing Medi-Cal provider networks with the providers serving over 700,000 dually eligible Californians who have traditional fee-for-service (FFS) Medicare. The report highlights several noteworthy gaps that plans should pay attention to as they develop their networks. RAND’s key findings include:

• Differences in networks. Only 60% of clinicians providing visits to FFS Medicare dually eligible enrollees were also found in Medi-Cal managed care provider listings.
• Wide variation. While 65% of primary care physicians seen by FFS Medicare dually eligible enrollees were included in Medi-Cal lists, the rate was much lower for specialists like psychiatrists (47%).
• Gaps in key settings. Less than half (47%) of clinicians providing visits to FFS Medicare dually eligible enrollees in skilled nursing facilities were listed in the Medi-Cal managed care provider listings.
• Concentrated care. A small subset of clinicians (18%) provided 80% of all visits for FFS Medicare dually eligible enrollees, meaning a small group of clinicians is providing a disproportionate amount of care.

Looking Ahead: What can managed care plans and policymakers do to ensure enrollees in both Medi-Cal and Medicare can continue seeing their regular providers?

As these new plans continue to roll out, the RAND report identifies several opportunities for managed care organizations (MCOs) and policymakers to develop optimal provider networks that ensure continuity and access to care.

Opportunity	MCOs	Policymakers
Leverage data	Use data and market insights to identify and address gaps in provider networks.	Analyze care patterns among different types of enrollees to ensure provider networks are responsive to all enrollees.
Target outreach	Engage more clinicians for Medicare Medi-Cal Plan contracting.	Examine and address potential care disruptions among specialties and regions in which care is concentrated among fewer clinicians.
Develop resources	Provide clearer information about providers on consumer-facing materials.	Develop benchmarks for network access.
Monitor implementation	Monitor both enrollment and disenrollment patterns.	Monitor whether plans are adapting their networks to meet the needs of all Californians who could benefit from these plans.

Read the full report: Building Provider Networks for Enrollees in Both Medicare and Medi-Cal, CHCF, January 2025.