Building Provider Networks for Enrollees in Both Medicare and Medi-Cal

Navigating separate Medicare and Medi-Cal systems can lead to fragmented care for dually eligible Californians, affecting their health outcomes. To address this, the California Department of Health Care Services (DHCS) is implementing CalAIM (California Advancing and Innovating Medi-Cal) strategies, including the introduction of Medicare Medi-Cal Plans, technically known as Exclusively Aligned Enrollment Dual Eligible Special Needs Plans (D-SNPs). These plans, which are managed by the same organizations as Medi-Cal managed care plans, aim to improve care coordination by consolidating services under one organization. Launched in 2023, these plans are now in place in 12 counties and will be expanded to many additional counties by 2026.

The Importance of Provider Networks

Dually eligible Californians can choose between fee-for-service (FFS) Medicare or Medicare Advantage plans, including D-SNPs. To attract members to Medicare Medi-Cal Plans, managed care organizations (MCOs) must offer robust provider networks that maintain continuity with clinicians. Dually eligible enrollees with FFS Medicare represent a significant potential membership pool for these new plans. Successful Medicare Med-Cal Plans will need provider networks that not only align closely with existing Medi-Cal networks, as recommended by DHCS, but also include those providers serving dually eligible enrollees through Medicare.

A RAND study explores the overlaps and gaps between clinicians serving dually eligible enrollees with FFS Medicare and Medi-Cal provider networks, highlighting areas where MCOs might need to seek out providers beyond their Medi-Cal networks. This report aims to inform MCOs, policymakers, and other stakeholders about opportunities to assess, develop, and monitor these Medicare Medi-Cal Plan provider networks so that they appeal to and better serve dually eligible enrollees.