References: Title 22 CCR §§53800-53898 for Two-Plan Model, §§53900-53928 for GMC

In 12 counties, certain Medi-Cal recipients are required to receive Medi-Cal in one of two contracted managed care plans. This is called the Two-Plan Model Managed Care Program. In Sacramento and San Diego counties, Medi-Cal services are provided through several managed care plans. This is called Geographic Managed Care (GMC).

Full scope Medi-Cal recipients in Two-Plan or GMC counties who have a $0 share of cost and are linked to the AFDC program as described in the §1931(b) of the Social Security Act (as amended by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996) or children under age 21 who receive Medi-Cal as Medically Indigent are required to enroll in a managed care plan. (see Title 22 CCR §§53845 and 53906)

In Two-Plan model counties and GMC counties, persons who are otherwise mandatory enrollees are permitted to not enroll or to disenroll from the managed care plan by requesting a medical exemption. (See Title 22 CCR §53887 for this exemption in Two-Plan model counties and Title 22 CCR §53923.5 for the medical exemption in GMC counties).

Note: Beneficiaries in County Organized Health Systems (COHS) may not disenroll from the COHS. There are seven COHS counties. These counties are Monterey, Napa, Orange, San Mateo, Santa Barbara, Santa Cruz, and Solano.

The purpose of the medical exemption is to permit an eligible Medi-Cal beneficiary who is about to be enrolled in a managed care plan to continue to be treated by a physician who is not a contracted provider with a Medi-Cal managed care plan. The physician must be participating in the Medi-Cal program. In order to establish the medical exemption, the beneficiary must meet one of several criteria to receive continued fee-for service Medi-Cal. Those criteria are found at Title 22 CCR §53887 for Two-Plan model counties and Title 22 CCR §53923.5 for GMC counties.

The most common issue at hearing is when the beneficiary alleges he/she needs a medical exemption because he/she has a "complex or high-risk medical condition" that requires continuity of care from the fee-for-service Medi-Cal physician. The following discussion is about exemption or disenrollment from managed care based on an alleged complex or high-risk medical condition.

A Medi-Cal beneficiary who is a mandatory enrollee receives a packet of information about the managed care plans in his/her county of residence before enrollment. Included in that packet is a medical exemption certification form (HCO-02).

If a Medi-Cal beneficiary is being treated by a physician who accepts fee-for-service Medi-Cal at the time he/she is enrolled in a Medi-Cal managed care plan, the beneficiary may give the HCO-02 medical exemption certification form to the fee-for-service physician. The fee-for-service physician then completes the HCO-02 and submits it to the Medi-Cal Managed Care Health Care Options enrollment contractor (HCO). If the physician accepts fee-for-service Medi-Cal and also participates in a Medi-Cal managed care plan, HCO will deny a request for medical exemption because the beneficiary may enroll in the managed care plan that the physician participates in. Note: Although Title 22 CCR §§ 53887 and 53923.5 refer to physician, the HCO applies those sections to providers including providers who are not physicians such as osteopaths, acupuncturists or chiropractors.

The HCO evaluates each request for medical exemption. If the HCO determines that the beneficiary has a complex or high-risk medical condition that requires continuity of care, it will exempt/disenroll the beneficiary. Once a beneficiary is exempted/disenrolled, any fee-for-service only provider who participates in Medi-Cal may treat him.

For example, John Beneficiary resides in a Two-Plan model county. Dr. Smith, a fee-for-service orthopedist who participates in Medi-Cal, submits a written request for medical exemption from Plan A Health Care plan on behalf of John Beneficiary because he needs to see John for follow-up care after extensive back surgery. (Note: Per HCO, the written request must be on the HCO-02 form. No substitute form is permitted). If HCO approves the medical exemption request, John is no longer a member of Plan A Health Care Plan. Medi-Cal will now authorize payment for John to be treated by his Medi-Cal fee-for-service eye doctor, internist, or chiropractor.

If the request for medical exemption is approved, John will not have to join a managed care plan for "up to 12 months". Shortly before the medical exemption is about to expire, the HCO will send a written notice to John advising him that a new HCO-02 needs to be completed or John will be enrolled in a managed care plan. Dr. Smith will have to complete a new HCO-02. If no new HCO-02 is submitted, John will receive a new packet to enroll into a managed care plan. Once enrolled in a managed care plan, John may not be treated by any fee-for-service physician unless Dr. Smith or some other Medi-Cal fee-for-service physician submits another HCO-02 form and HCO approves another medical exemption.

Since the intent of the medical exemption is to avoid disruption of continuity of care, the medical exemption only applies if the beneficiary is being treated by a Medi-Cal fee-for-service physician at the time of enrollment in the managed care plan.

A medical exemption into fee-for-service Medi-Cal is not appropriate for those who are enrolled in a managed care plan and who were not seeing a Medi-Cal fee-for-service physician prior to enrollment or who were seeing a Medi-Cal fee-for-service physician prior to enrollment, but not for a complex or high-risk medical condition. If a beneficiary is dissatisfied with treatment he/she is receiving from his/her managed care plan, he/she may call the ombudsman at 1-888-452-8609.

The HCO must act on the merits of each case and evaluate each HCO-02. Under current regulations, there is no basis for HCO to deny a request for medical exemption solely because the beneficiary has been in a managed care plan for 60 days or any other time period. (Under current practice, a Medi-Cal beneficiary is automatically enrolled in a managed care plan if no HCO-02 is submitted within 60 days after the beneficiary receives the enrollment packet).

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