Open-enrollment headache again strikes Covered CA

November 14, 2014 By Dave Roberts 1 Comment

If you thought the rollout of Obamacare was problematic last year, this year could be worse — including its implementation here, called Covered California.

State officials are still struggling to clear a huge backlog of Medi-Cal applications from the past year, while legislators field numerous complaints from frustrated constituents, insurance premiums are increasing and Medi-Cal renewals are down. The open enrollment period for 2015 begins Nov. 15.

“As much as the first year of enrollment was big and rocky, on some levels the second year is going to be harder,” said Covered California Executive Director Peter Lee at a recent Senate Health Committee informational hearing.

Both Lee and Department of Health Care Services Director Toby Douglas are proud of their progress in implementing Obamacare in California.

“We reduced the number of uninsured by 3.4 million people in this state, from 22 to 11 percent,” said Lee. “That’s the largest reduction by percentage in the entire nation. We can feel proud of California serving as an example for the nation how to do this right.”

“[We] have had tremendous success with the implementation of the Affordable Care Act,” agreed Douglas. “We have within our Medi-Cal program dramatically changed the perception. The perception overall is positive and it gets high marks.

“That being said, we’ve had challenges, many challenges with the process. We know our implementation has not been without problems. We have to continue to learn from those challenges, continue to improve it and make it a better experience for all of those, whether applying for Covered California or enrolling into our Medi-Cal program.”

Backlog

One of DHCS’s biggest challenges has been clearing the Medi-Cal application backlog. It had reached 487,000 pending applications in July, which were whittled down to 171,681 by Oct. 15. Nearly 1,400 applicants have been waiting a year to find out whether they’ll receive coverage.

This has not only been an embarrassment for state health officials, but it’s also illegal. State law requires that health insurance applications either be accepted or denied within 90 days. Several social advocacy organizations have filed a lawsuit to get the state to abide by its own law.

“There has been an increase recently,” acknowledged Douglas. “Covered California has been going through administrative renewals, and that has pushed populations over to Medi-Cal. And we know that there’s at least 40,000 that are duplicates that need to be denied within the system of 171,000. And there’s 20,000 where we’re looking at our administrative strategies that are eligible.

“We have been going through a lot of different enhancements to try to reduce the pending cases and bring it down. Our ultimate goal is we want all applications determined eligible in the required time frame. And we might still always have pending cases, because counties might be waiting for verification information. But we want to make sure that there is no one out there stuck and pending because of system problems.”

Renewal

Another challenge for Douglas is getting Medi-Cal recipients to renew their coverage. The renewal rate in 2013 was 60-70 percent in many of the state’s larger counties. But that range has dropped to 50-70 percent in 2014, with some counties below 50 percent.

That decrease concerns Sen. Holly Mitchell, D-Los Angeles. “This is deeply troubling,” she said. “We spend all this energy talking about congratulating ourselves about our enrollment numbers and that number will be a moment in time because we get to re-enrollment and we lose them.

“And the Legislature will have kneejerk reactions like, ‘Get rid of the status reports, get rid of this, get rid of that’ to try to fix that number. That’s why I ask what the problem is so we can be a partner rather than kneejerk to try to plug this hemorrhage – because that’s huge and a problem.”

Douglas responded, “We’re not sure. We delayed the actual disenrollments to get more outreach. We would have thought it would be the same. This is not what we wanted. We think it’s because it’s a new process. There’s been concern from community groups that … thought it was confusing. It’s going to take a lot of grass roots work to break down and understand this new process and why it’s different.”

Mitchell said the confusion is inherent in the way government does things.

“Government does a horrible job in communicating,” she said. “At first I thought it’s because we really don’t want to enroll people. And I don’t think that’s the case. We are bitten by the IRS bug. Every form we create we have to make it as complicated, use as many words and make it look as academic and unfriendly as possible. It’s not just you, it’s government across the board. I’m not sure why that is. We have a bad habit of making the process as difficult and complicated unnecessarily as possible.”

Lee disagreed: “We certainly don’t, as either a matter of habit or purpose, try to make things complex, as you know.”

That prompted Mitchell to laugh, saying, “It’s government – we can’t help ourselves.”

Outreach

She also criticized the state’s education and outreach efforts to blacks.

“The effort in the first go around was lackluster,” she said. “And we need to have a clear conversation and commitment around who is engaged and contracted to do the advertising and outreach to this very specific and targeted community.

“I sponsored a [Covered California] storefront [in the Crenshaw mall] because I happened to think it was a great idea when I was approached by community-based organizations. But I have to say, I was quite disappointed at the outcome. We had five kazillion touches, but our enrollment numbers were nowhere near what I anticipated.”

Lee responded, “The Crenshaw mall enrolled not as many people as you thought it would and we thought it would. But a lot of people came and asked questions. And one of the things we learned is that it’s not a one-touch-and-done enrollment process. So the fact of having a storefront where people can come in, ask questions, take material home, come in again and then maybe go enroll with an insurance agent at that storefront we say, ‘Hallelujah, wherever you are enrolling is OK.’”

Calls

Committee Chairman Sen. Ed Hernandez, D-West Covina, voiced a complaint made by legislators at an Assembly Health Committee hearing on Obamacare in September.

“My office on a regular basis is getting calls,” he said. “They get funneled up to Sacramento. These are people who are in support of the Affordable Care Act. And they are just really upset. It can be anything from [a lack of] network adequacy to call time to wait time to length of time in Medi-Cal to get enrolled.

“So I want to make sure that not only California continues to be the leader, but absolutely most important that we address as many if not all of the concerns that the consumers of the state of California have.”

Sen. Bill Monning, D-Monterey, has also received numerous complaints from constituents.

“I represent rural areas where in much of my district there is no competition” among health insurance providers, he said. “Our phones are ringing off the hook with people who have coverage and can’t find a [health care] provider who will accept that coverage. So, coverage without access is not real coverage.

“We have a health care plan in Monterey County advising providers at a local hospital that diabetes prevention is not covered. It’s wrong. They are giving disinformation, turning people away. A major health plan that is our only health plan in the region of Monterey County is advising providers it will not cover preventing for diabetes.”

Lee said preventive care is covered, and insurance companies are reviewed annually to make sure they are providing adequate coverage.

“When we sit down with health plans, we don’t say the first question is: What’s the cost?” he said. “The first question is: Are there adequate networks of doctors, hospitals to make sure people get the necessary care? Not all, but in a number of cases there were areas where we specifically said there appear to be shortfalls in networks. And part of what plans came in with was expanded networks of hospitals or of doctors.”

Lee and Douglas assured the committee that they are working to fix the problems and improve service, but acknowledged that will take time.

This article was originally posted on CalWatchdog.com.

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Quarter-million applicants still waiting for Medi-Cal

September 30, 2014 By Dave Roberts 1 Comment

Originally published on CalWatchdog.com:

A quarter-million Medi-Cal applicants have been waiting more than 45 days, and in some cases nearly a year, either to receive coverage or find out why their application has been denied.

That’s an improvement from the 900,000 applicants who were languishing in early summer without coverage or word from Medi-Cal. But it will take another six weeks for most of the remaining 250,000 residents to receive or be denied coverage, according to Department of Health Care Services Director Toby Douglas.

At a Sept. 23 Assembly Health Committeeoversight hearing, Douglas touted the Medi-Cal expansion as a “tremendous success,” but cautioned the enrollment backlog may never be totally cleared.

Legislators expressed frustration that their constituents are being dropped from coverage without notice, getting the run-around when they try to find out what’s happening with their applications or never being informed about the potential for Medi-Cal coverage in the first place.

“It’s taking months – months – to check on the status of cases,” said Assemblyman Jim Patterson, R-Fresno. “We are completely unable to help constituents in a timely manner. And it’s happening over and over again.”

Patterson said applicants seeking information are getting caught in what he called a referral loop. “They are told the state is just a billing agency and they need to contact the county,” he said. “The county says, ‘It’s not our job, you have to go talk to the state.’ This is a loop that’s going on and on. We get the concerns that they are bounced from person to person, and everyone saying they can’t address the issue and they need to call somebody else.”

Covered California

Two million patients have been added to the Medi-Cal rolls the past year through the new Covered California exchange, part of the federal Affordable Care Act, or Obamacare. Medi-Cal now covers 11 million Californians – about 29 percent of state residents. The Medi-Cal budget is more than $90 billion, an 80 percent increase from just four years ago, according to committee ChairmanAssemblyman Richard Pan, D-Sacramento.

The application-processing delays have been due to the unexpectedly large increase in applications, technical snafus and administrative decisions to delay coverage until residency and income are verified, according to Cathy Senderling, deputy executive director of the County Welfare Directors Association.

“We are in a situation where it’s been incredibly exciting to have the Affordable Care Act after so much planning,” she said. “But it’s also been very frustrating for our workers and we know for our customers as well.”

Most of the 250,000 cases remaining in the backlog are in some stage of being worked on, she said. “Many of them actually need to be denied. And the capacity of the system has not yet been brought up to be able to do that because of the way it was programmed and the confusion that would be created for our customers.”

Patterson argued that these kinds of snafus are inherent in “a state-run and sort of a command-and-control approach to health care.”

“We asked for this,” he said. “By doing the things we have done, by taking this Affordable Care Act, putting a California overlay on it and the 2 million additional, all of the things that we have done, we should have understood that this would be the result, that we were going to end up with significant bureaucratic problems, that we were inviting these very kinds of problems.

“So I think to suggest that we are the victims of success doesn’t sit well with the people that are trying to be the examples of the success. And so the backlogs, the payment, the notifications, the dropping of individuals, all of this is really creating a serious matter of an urgent level. And I hope that you can take that back to your organization and the governor and others in charge.”

Backlog

Elizabeth Landsberg, director of legislative advocacy for the Western Center on Law and Poverty, pointed out that many of the hundreds of thousands of people stuck in the Medi-Cal backlog have suffered as a result.

“Some people are going without health care and having terrible health consequences,” she said. “Some can’t get care tests because they can’t pay out of pocket for them. And some are going into medical debt and facing collections because of it. This is a story about real people, our neighbors, our friends, our fellow Californians.

“It’s a story about a woman with severe pain from diverticulitis who has been using the emergency room when her pain is severe. The doctor said she needs to get non-urgent treatment of the condition to prevent the severe pain and the trips to the emergency room. We have patients going to the emergency room, but they cannot get on Medi-Cal and get the care that they need. Emergency rooms don’t provide that.

“This is story of a woman who applied through the Covered California portal in December, was told she should be eligible for Medi-Cal. She has medical bills from May 2014 and she has a hospital threatening her with collection actions against her. This is the story of a man who also applied nine months ago and has to pay out of pocket for insulin pump supplies and was hospitalized for diabetes complications affecting his heart.”

Landsberg said the state is not informing applicants of “their right to file for a fair hearing if they don’t have a timely eligibility determination. State law is clear, we have to make these decisions within 45 days.”

Her organization, along with several other advocacy groups, filed a lawsuit in Alameda County Superior Court on Sept. 17, Rivera vs. Toby Douglas, seeking to force the state to comply with its own law.

“Consumers simply don’t know that something’s going wrong if they don’t get an answer,” said Landsberg. “They get one notice from Medi-Cal saying, ‘We think you’re eligible for Medi-Cal, you’ll hear if you are.’ Many people still are familiar with the old rules where childless couples weren’t eligible for Medi-Cal. They don’t know that something’s wrong.”

Access

Assemblyman Roger Hernandez, D-West Covina, is also concerned that his constituents are being left in the dark.

“People are asking how we get folks connected with access to health care,” he said. “I’m concerned representing a community … where we see a high level of immigrant, working class, Latino and minority populations that are not having the same access to registration and information about how to sign up as other non-Latino groups are. That’s a problem in terms of outreach.”

Douglas assured the committee that improvements are being made. “Everyone is working around the clock,” he said. “What I want to report to you, and where we will get soon, is that every individual that applies and is providing all the information necessary will get enrolled in the program in the appropriate timeframes. And that’s what we need to get to. And we’re not there yet.

“The system continues to get a lot better. This continues to be a work in progress. We were quick in implementing health care reform. And it’s going to take next year still to work through some of these final system stages.”

He cautioned, though, that as his department works to get things right with the first year of Medi-Cal applications through the Covered California exchange, those applications will soon be coming up for renewal, potentially creating new challenges.

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