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Thursday, February 22, 2024

Medi-Cal’s Fragmented System Can Make Transferring a Nightmare


When Lloyd Tennison moved from Walnut Creek to Stockton final 12 months, he assumed his protection underneath Medi-Cal, California’s safety-net medical health insurance program, could be transferred seamlessly.

About three weeks earlier than his Could transfer, Tennison known as the company that administers Medi-Cal in Contra Costa County, the place Walnut Creek is positioned, to tell them he’d be transferring to San Joaquin County.

Little did he suspect his switch would get tangled in pink tape, disrupt his care, and saddle him with two payments totaling almost $1,700 after he was faraway from his previous plan with out discover earlier than his new one in Stockton took impact.

Medi-Cal members who transfer counties are sometimes bumped quickly from managed care insurance coverage into conventional Medi-Cal, also called “payment for service,” during which the state pays suppliers straight for every service rendered. However managed care practitioners who don’t take part in conventional Medi-Cal haven’t any strategy to receives a commission once they see such sufferers, they usually typically invoice them straight — despite the fact that that’s prohibited.

Medi-Cal is a statewide program, however it’s administered by the counties, which have separate authorities bureaucracies and completely different approaches to care: Some have only one county-operated Medi-Cal plan. Others have solely business well being plans, that are paid by the state to handle the care of Medi-Cal sufferers. Many have certainly one of every.

Touring from Walnut Creek to Stockton takes somewhat greater than an hour by automobile, however so far as Tennison is worried, the 2 cities would possibly as nicely be on reverse sides of the planet.

Tennison, 63, wanted a clean well being care transition. With extreme power ache in his again, shoulders, and neck, he requires common bodily remedy and monitoring by an orthopedist, in addition to a number of ache drugs. He additionally has carpal tunnel syndrome and Kind 2 diabetes.

Due to miscommunication and confusion surrounding his transfer, a number of bodily remedy appointments he’d made for June 2022 had been canceled, and he needed to wait almost two months for brand spanking new ones.

“To me the entire problem is the confusion,” Tennison mentioned. “Proper hand and left hand, no one talks to one another, and no one talked to me.”

The primary trace of bother got here when he known as Contra Costa County Employment & Human Providers in late April 2022 to report his upcoming transfer and was instructed the brand new county needed to provoke the switch — solely to listen to from a employee at San Joaquin’s Human Providers Company that it was the opposite manner round.

They had been each flawed: Medi-Cal members who transfer can inform both county.

Tennison persuaded a Medi-Cal employee in San Joaquin County to provoke the switch. He additionally filed a discover of his transfer on-line, which Medi-Cal staff in Contra Costa processed and flagged for a June 2 switch date, mentioned Marla Stuart, director of the county’s Employment & Human Providers Division.

They set that date, Stuart mentioned, as a result of they believed Tennison may need some medical appointments in Could underneath his Contra Costa Anthem Blue Cross plan.

Medi-Cal staff in San Joaquin County, nevertheless, set a transfer date of Could 5, which overrode Contra Costa’s June 2 date and bumped Tennison from his Anthem plan for many of Could, in line with Stuart.

“If anyone had known as me to confirm any of this, I positively would have instructed them Could 5 was the flawed date,” mentioned Tennison, who moved to Stockton on Could 17.

“There have been good intentions throughout,” mentioned Stuart. “It’s unlucky what occurred.”

Being lower from Anthem left Tennison with fee-for-service Medi-Cal, a quickly shrinking a part of this system.

He found it solely in mid-July, when he known as the Workplace of the Ombudsman for managed care Medi-Cal to complain about two payments he’d acquired — one for $886.92 from his orthopedic surgeon and one other for $795 from his bodily therapist.

He had seen each suppliers in Could, when he thought he was nonetheless coated by Anthem. However he wasn’t, they usually billed him straight, regardless of signed agreements and a state regulation that prohibit billing sufferers for companies coated by Medi-Cal.

The payments caught Tennison abruptly, as a result of the ombudsman had instructed him in early June that he had nonetheless been on Anthem by means of Could, he mentioned.

“To me, that’s how insurance coverage works: One insurance coverage ends, the opposite begins,” he mentioned.

When Medi-Cal sufferers are between well being plans and quickly in payment for service, it theoretically ensures they’ve ongoing entry to well being care. However in follow, that’s not all the time the case.

“As a result of the state is pushing most Medi-Cal members into managed care, fewer suppliers are accepting payment for service,” mentioned Hillary Hansen, an lawyer with Authorized Providers of Northern California who’s dealing with Tennison’s case.

The prohibition towards billing Medi-Cal sufferers is spottily enforced, Hansen mentioned. And though the sufferers should not legally required to pay, she mentioned, their credit standing can endure in the event that they don’t. Michael Bowman, a spokesperson for Anthem, mentioned the corporate frequently communicates with its suppliers to make sure compliance with the phrases of their contracts and Medi-Cal guidelines.

Hansen will not be assured Tennison’s payments will likely be paid anytime quickly. After authorized help attorneys despatched a letter to state officers about improper Medi-Cal billing, and later met with them about it, the officers instructed them to have their shoppers submit reimbursement claims.

However the reimbursement guidelines require that sufferers have already paid the payments, and Medi-Cal beneficiaries usually can’t afford that, Hansen mentioned.

Tennison submitted his reimbursement type in Could and is ready to listen to again. “Getting medical care shouldn’t be this tough,” he mentioned. “Right here it’s a 12 months later, and I’m nonetheless attempting to work this out.”

KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working packages at KFF—an unbiased supply of well being coverage analysis, polling, and journalism. Study extra about KFF.

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