Eligibility Criteria for Cal MediConnect
- Participating Physician Groups (PPG)
Cal MediConnect is available to individuals who meet all of the following criteria:
- Age 21 and older at the time of enrollment.
- Entitled to benefits under Medicare Part A, and enrolled for benefits under Medicare Part B and eligible for Part D.
- Eligible for full Medi-Cal benefits, including:
- Individuals enrolled in the Multipurpose Senior Services Program (MSSP).
- Individuals who meet the share of cost provisions below:
- Nursing facility residents with a share of cost.
- MSSP enrollees with share of cost.
- Individuals eligible for full Medicaid (Medi-Cal) per the spousal impoverishment rule codified at section 1924 of the Social Security Act as described below:
- For those members who are nursing facility level of care, subacute facility level of care, or intermediate care facility level of care and reside or could reside outside of a hospital or nursing facility, the Department or its designee shall make a Medi-Cal eligibility determination "as if" the beneficiary were in a long-term care facility. Specifically, the spousal impoverishment rule codified section 1924 of the Act will apply to members. The terms "intermediate care facility level of care" and "nursing facility level of care" and "subacute facility level of care" shall have the same meaning as defined in Title 22 of the California Code of Regulations sections 51120, 51124, and 52224.5.
- Reside in one of the following demonstration counties: Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara.
- Up to 200,000 individuals in Los Angeles may be enrolled in the demonstration. The Centers for Medicare & Medicaid Services (CMS) and Department of Health Care Services (DHCS) will monitor the enrollment and stop participation when this enrollment cap is met.
- Individuals residing in San Mateo or Orange counties with a diagnosis of end-stage renal disease (ESRD) at the time of enrollment.
Individuals who meet the following criteria are not eligible for Cal MediConnect:
- Under age 21.
- Have other private or public health insurance.
- Receiving services through California's regional centers or DHCS developmental centers or intermediate care facilities for the developmentally disabled.
- Have a share of cost who do not meet the enrollment requirements outlined above
- Reside in one of the Veterans' Homes of California.
- Reside in certain rural ZIP codes of San Bernardino, Los Angeles and Riverside.
- Have a diagnosis of ESRD at the time of enrollment and residing in Alameda, Los Angeles, Riverside, San Bernardino, San Diego, and Santa Clara, unless they are already enrolled in a separate line of business operated by Health Net (individuals enrolled in the demonstration who are subsequently diagnosed with ESRD may choose to stay enrolled or choose to disenroll from the demonstration.