24-1308m Find Out What's Changing for Partial Dual Eligible Medi-Cal Members in 2025

Date: 12/20/24

Senate Bill 311 makes California a Part A buy-in state

Effective January 1, 2025, per California Senate Bill 311, the state’s Medi-Cal program will pay Medicare Part A premiums for eligible individuals who are not automatically enrolled in Medicare Part A.

How this affects patients, physicians and other providers

Patients who were previously ineligible for Medicare Part A will now have access to Medicare fee-for-service hospital benefits and related services. These patients were likely ineligible for Medicare A because they worked an insufficient number of quarters to qualify.

Because these beneficiaries will now be eligible for Medicare Part A, B, D and are fully covered by Medi-Cal, they will be eligible for Medicare Advantage plans, including Dual Eligible Special Needs Plans (D-SNPs). As a result, physicians and other providers may experience an increase in patients who have D-SNPs.

In 2025, the Plan will offer D-SNP Plans in many counties, including Los Angeles, Sacramento, Tulare, Fresno, Kings, Madera, Amador, Calaveras, Tuolumne, Imperial and Stanislaus. In these counties, eligible members who formerly had only Medi-Cal may now qualify for help paying for Medicare Part A and become covered by a D-SNP.

Additional information

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
Behavioral Health providers can call at 844-966-0298.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.