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

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


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

About three weeks earlier than his May transfer, Tennison referred to as the company that administers Medi-Cal in Contra Costa County, the place Walnut Creek is positioned, to tell them he’d be shifting 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, often known as “fee for service,” during which the state pays suppliers instantly for every service rendered. But managed care practitioners who don’t take part in conventional Medi-Cal haven’t any approach to receives a commission once they see such sufferers, and so they typically invoice them instantly — 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 totally 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 one in all every.

Traveling from Walnut Creek to Stockton takes just a little greater than an hour by automotive, however so far as Tennison is anxious, the 2 cities may as effectively be on reverse sides of the planet.

Tennison, 63, wanted a clean well being care transition. With extreme continual 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 Type 2 diabetes.

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

“To me the whole issue is the confusion,” Tennison mentioned. “Right hand and left hand, nobody talks to each other, and nobody talked to me.”

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

They have been each unsuitable: Medi-Cal members who transfer can inform both county.

A photo of a man in a scooter backing out of a van in a parking lot.
Tennison takes his motorized scooter off the van he took to a medical appointment in Stockton, California.(Heidi de Marco / KFF Health News)

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 employees in Contra Costa processed and flagged for a June 2 switch date, mentioned Marla Stuart, director of the county’s Employment & Human Services Department.

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

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

“If anybody had called me to verify any of this, I definitely would have told them May 5 was the wrong date,” mentioned Tennison, who moved to Stockton on May 17.

“There were good intentions all around,” mentioned Stuart. “It’s unfortunate what happened.”

Being minimize 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 referred to as the Office 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 May, when he thought he was nonetheless lined by Anthem. But he wasn’t, and so they billed him instantly, regardless of signed agreements and a state legislation that prohibit billing sufferers for providers lined by Medi-Cal.

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

“To me, that’s how insurance works: One insurance ends, the other 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. But in apply, that’s not at all times the case.

“Because the state is pushing most Medi-Cal members into managed care, fewer providers are accepting fee for service,” mentioned Hillary Hansen, an legal professional with Legal Services 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 recurrently communicates with its suppliers to make sure compliance with the phrases of their contracts and Medi-Cal guidelines.

Hansen shouldn’t be assured Tennison’s payments will probably be paid anytime quickly. After authorized help legal professionals 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.

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

Tennison submitted his reimbursement kind in May and is ready to listen to again. “Getting medical care should not be this difficult,” he mentioned. “Here it is a year later, and I’m still trying to work this out.”

A photo of a man sitting in a chair with a blood pressure cuff around his arm and a pulse oximeter on his finger.
Tennison will get his blood strain, blood oxygen stage, and pulse fee measured at a medical appointment in Stockton.(Heidi de Marco / KFF Health News)

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