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Proposal to Transition HFP Kids to Medi-Cal

Summary of the Proposal

This morning, DHCS hosted a stakeholder meeting on the proposed transition of Healthy Families (HFP) to Medi-Cal. A recently proposed trailer bill would require all HFP enrollees with family incomes up to 250% FPL to transition to Medi-Cal over a 9-month period, beginning either October 1, 2012 or 90 days after the bill is enacted (which ever date is later).  There are currently 875,000 eligible beneficiaries who would be involved in this transition. The transition would occur in three phases.

The Transition Process

Phase 1 – 90 days after enactment or October 1, 2012

HFP beneficiaries enrolled in plans that are also Medi-Cal managed care plan should be enrolled in the same plan, unless they choose a different Medi-Cal managed care plan. This will involve 411,506 enrollees.

Phase 2 – No earlier than January 1, 2012

HFP beneficiaries enrolled in an HFP managed care plan that is a subcontractor of a Medi-Cal managed care plan will be enrolled into a Medi-Cal managed care plan that includes their current primary care provider, unless they choose a different Medi-Cal managed care plan. These individuals are the remaining HFP enrollees that live in counties with Medi-Cal managed care plans that were not included in Phase 1. This will involve 416,605 enrollees.

Phase 3 – No earlier than January 1, 2013

HFP beneficiaries residing in a county that is not a Medi-Cal managed care county will receive services under the Medi-Cal fee-for-service system. These individuals will receive services through managed care once DHCS expands managed care to those counties in June 2013. This will involve 42,561 enrollees.

Above: Breakdown of total numbers of members in each plan.

Above: Timeline of the entire process, starting with initial DHCS/MRMIB meetings and ending with 1-year reports.

Change in Enrollment Structure for Future Enrollees

In both the current and future enrollment paths, applicants can apply through the County Welfare Office (either in person, online, or by mail) or MAXIMUS (either online or by mail). In the current system, those who screen for HFP are sent to HFP MAXIMUS and those who screen for Medi-Cal are sent to the county. In the future system, MAXIMUS provides premium and case management support to those who qualify for Share of Cost, but all cases are sent to the county.

Current Enrollment Path

In the current enrollment path, MAXIMUS screens applications for no-cost Medi-Cal/HFP, grants accelerated enrollment to children eligible for no-cost Medi-Cal and sends applications to the county of residence for no-cost Medi-Cal or HFP determination. The county completed eligibility determinations and send applications to HFP when the children have a share of cost. Then, HFP MAXIMUS determines HFP eligibility, enrolls the child in a health plan, provides premium management, conducts annual renewals, and refers HFP cases to counties for Medi-Cal determination when family income drops.

Future Enrollment Path

In the future enrollment path, MAXIMUS will review for completeness and screen all cases for final eligibility determination and the county will complete the eligibility determination for all children up to 250% FPL.  Children under 150% FPL (no-cost Medi-Cal) will be provided ongoing case maintenance by the county and children between 150% and 250% will be referred to MAXIMUS for ongoing case maintenance and premium collections.

Change in Eligibility Determinations

Current Eligibilities








Future Eligibilities






Changes in Reimbursements

Currently, out-of-network providers receive adequate reimbursements for providing emergency care to HFP enrollees while in-network providers receive HFP rates. Under Medi-Cal, out-of-network provider receive Medi-Cal rates for providing emergency care to Medi-Cal enrollees and in-network providers receive their contracted rates. This transition could pose issues for those who currently receive adequate reimbursements for providing emergency care to HFP enrollees.

Benefits to the Transition

Unified Family Coverage

Children will no longer have to transition between programs when the family income fluctuates. From 2009-2010, 42% of HFP children were eligible for Medi-Cal at some point over the previous three years.

No Wrong Door

Families can apply at a county, by mail or online.

Reduced Cost-Sharing

Children in families with incomes below 150% FPL will no longer pay premiums or co-payments. Families between 100 and 150% FPL currently pay monthly premiums between $4 and $14 and co-payments between $5 and $15 for services.

Expanded Benefits

Children will receive retroactive coverage for 3 months prior to their application, access to free vaccines, and those under 21 have access to the EPSDT program, which may also deem them eligible for the full range of Medi-Cal Specialty Mental Health Services.

Significant Plan and Provider Continuity

Most children will be able to remain with their existing plan. Data shows that 78% of HFP children are enrolled in a plan that participates in both Medi-Cal and HFP and 84% of providers contract with the plan for both HFP and Medi-Cal programs.

More Stable Plan Choices

HFP commercial health plan participants have been declining.

Simplified Contracting

With the 84% overlap of HFP and Medi-Cal providers, this will eliminate the need to manage two different contracts (one with DHCS and one with MRMIB).

Other benefits include: Consolidating Health Care Entitlement Programs, Simplifying Administration of Two Major Public Coverage Programs, Improving Plan Accountability and Monitoring, Achieving General Fund Savings, Aligning with More Consumer Friendly and Seamless Coverage System in 2014, Serves as Early Building Block for Successful Implementation of ACA.

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