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25-1155 Change to PPG/PCP Assignment for Dual-Eligible non-D-SNP Members

Date: 11/24/25

Aligning with DHCS guidance to streamline care coordination

We want to inform you of a change regarding the primary care physician (PCP) assignment of dual eligible members, also referred to as Medi-Medi members, that are not enrolled in a Dual Special Needs Plan (D-SNP)1 assigned to CalViva Health participating physician groups (PPGs).

  • This change does not affect members enrolled in D-SNPs. 
(1Full-benefit, dual-eligible members eligible for Medicare Part A and Medicare Part B and enrolled in both Medicare and Medi-Cal, also referred to as Medi-Medi members)

What’s changing?

In alignment with guidance from the California Department of Health Care Services (DHCS), which clarifies that:

  • No PCP assignment required: Managed care plans (MCPs) are not required to assign a Medi-Cal PCP to these members.
  • Medicare is the primary payer: These members receive their care primarily through their Medicare plan and providers, with their Medicare plan being the primary payer and Medi-Cal serving as the payer of last resort.

Effective February 1, 2026, dual-eligible non-D-SNP members who have selected CalViva Health as their plan will be assigned directly to CalViva Health, with Health Net paying claims secondary to the member’s Medicare coverage.

What does this mean for you?

  • Member assignment: dual-eligible non-D-SNP members will no longer be assigned to Medi-Cal PPGs and will be assigned to a placeholder PPG and see their Medicare provider effective February 1, 2026. PPG members will receive notification of this transition before January 1. PPGs will continue to provide care during the transition period.
  • Policy alignment and reduced confusion: This change ensures member assignments are consistent with state guidance and helps reduce confusion for both providers and members.
  • Ongoing process for newly identified age-in dual eligibles: Upon receiving notice of a PPG’s existing Medi-Cal members becoming full-benefit duals, they will be assigned to a placeholder PPG and can see their Medicare provider within 1-2 months.
  • Continued payment: If a dual-eligible non-D-SNP member is assigned to a PPG during the transition, the PPG’s contracted rates will still apply.
  • No changes to billing: PPGs may continue using existing billing procedures. No action is required for the PPG.

Need support or have questions?

We’re here to support our PPGs through this transition. For questions or additional information, please contact CalViva Health at 888-893-1569.

Thank you for your continued partnership in caring for our members.

 

This information applies to Participating Physician Groups (PPGs).

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

 



Last Updated: 11/24/2025