California is one of the first states to begin the process of Medicaid expansion as part of the Affordable Care Act. The first step in Medicaid expansion was to transition 380,000 seniors and persons with disabilities on Medi-Cal from fee-for-service to a managed care delivery system. Dr. Carrie Graham of HRA is evaluating beneficiary experiences with this mandatory transition, which was implemented between June 2011 and May 2012 as part of California’s Bridge to Reform Waiver. The evaluation is funded by the California Health Care Foundation and the California Department of Health Care Services (DHCS).

Background
There is some evidence that managed care may improve coordination of and access to care for beneficiaries. However, the transition to managed care risks disrupting existing care arrangements, a possibility that could be dangerous for this high-needs population. In implementing the transition, DHCS offered beneficiaries a choice between two or more Medi-Cal managed care plans in each county. For those who did not make a choice, DHCS searched fee-for-service utilization data to identify physicians that the beneficiary had seen in the past. If a beneficiary’s past provider was in the network of a particular plan, then DHCS assigned the beneficiary to that plan. DHCS also allowed beneficiaries with certain complex medical conditions to file a Medical Exemption Request to remain in fee-for-service Medi-Cal.

Major Objectives
This evaluation will determine the prevalence of positive, neutral and negative experiences among seniors and persons with disabilities who were mandatorily transitioned from fee-for-service Medi-Cal to Medi-Cal managed care. It will suggest means to identify categories of beneficiaries who are likely to have more difficulties with such transitions. It will assess whether efforts made to link beneficiaries with a plan network that includes providers seen in the past had any statistically significant effect on continuity of care or beneficiary satisfaction. Finally, the evaluation will examine whether the profile and experiences of beneficiaries who filed and were denied Medical Exemption Requests differed significantly from those of other Medi-Cal managed care enrollees.

Methods
The evaluation utilizes both telephone survey and focus group methodologies. The telephone survey—conducted in English and Spanish—will document the experiences of 1,515 randomly selected Medi-Cal beneficiaries who transitioned to Medi-Cal managed care between June 2011 and May 2012. Survey staff received special training for conducting interviews with persons with disabilities. Persons using sign language can take the survey through video relay or instant messaging technology. Other accommodations, such as the use of proxies, or completion of the survey in installments, are available as needed.

Focus groups supplement the telephone survey, allowing researchers to document the experiences of additional language groups, hard-to-reach populations, and small but medically vulnerable groups. The evaluation includes focus groups with the population’s three largest language groups after English and Spanish. These are Armenian, Vietnamese, and Chinese. Additional focus groups document the experiences of beneficiaries who are homeless or marginally housed, those on dialysis and those with developmental disabilities.