Ben Rockwell is a 68-year-old retired nurse with Parkinson’s disease and a long list of other health problems. He has to juggle two government health plans to make sure he gets the care he needs, but over the past two decades, he’s gotten good at it.
That’s why when he became eligible to join a new state health program, called Cal MediConnect, he decided he would pass. Because he knew how complicated coordinating his health care was, he didn’t want to hand off the process to a managed-care plan.
But despite California regulations stating that he had the right to keep his existing coverage — and his best efforts to do just that — it was changed anyway.
When Rockwell showed up for a health visit in July, he was told he couldn’t see the neurologist without authorization from a new primary-care physician that he had unknowingly been assigned. Further emphasizing the error was the fact that his new primary-care doctor was a pediatrician at a children’s hospital.
Critics of Cal MediConnect, including some health care providers and patients, are concerned that errors such as these may be impacting thousands of elderly and disabled California residents. They fear that the state has rushed the implementation of the new program in the hopes of saving money.
Implementation mistakes may put people like Rockwell at risk of losing access to supports and services they have spent decades carefully constructing.
“If this can happen to me it’s definitely going to happen to someone of lesser capabilities,” said Rockwell, who lives in Long Beach.
The Department of Health Care Services, meanwhile, says that patients have been adequately notified of the new program and that it’s designed to help them by streamlining their care.
Mistakes could hurt most vulnerable
Two patients, a doctor, the Los Angeles County Medical Association and three independent living centers banded together to sue the state over the implementation of Cal MediConnect.
The lawsuit, filed July 2 in the Superior Court of Sacramento, asked a judge to halt the program. But on Aug. 1, Judge Shellyanne Chang sided against the group behind the lawsuit. Rather than scrap the entire program, the state should remedy the issues, she wrote in the 13-page ruling.
Lynn Carman, chief counsel for the Medicaid Defense Fund and an attorney in the case, called the ruling “contrary to law and the evidence” and is preparing to challenge the decision.
In the meantime, stories similar to Rockwell’s continue to surface as the state tries to expand Cal MediConnect to as many as 456,000 people in eight counties: Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara. Ultimately 1.1 million people could be affected despite a record of fines and lawsuits against many of the managed-care plans selected by the state to coordinate care for a group that is elderly or disabled, with multiple chronic diseases and cognitive impairments.
They’re called “dual eligibles” because they rely on health insurance coverage from Medi-Cal, the state’s low-income health program, and Medicare, a federal health program for those 65 and older, as well as people with disabilities.
Enrollment process confusing
A snapshot from July 1 showed the state had enrolled 39,731 people in the program in five counties. Their Medi-Cal and Medicare coverage will be combined under Cal MediConnect and administered by a health maintenance organization, or HMO.
Another 38,428 people had opted out as of July 1.
Nancy Becker Kennedy joined the lawsuit because she did not want to lose access to her Medicare services and physicians.
“It took us ages to find a team of people who understand our problems,” she said. “You have the right to stay with the doctors who kept you alive.”
Not all advocates are in favor of freezing Cal MediConnect because the program has the potential to improve care. But like Kennedy Becker, they worry that people won’t realize they have a choice to not enroll because the Cal MediConnect forms may be confusing to them. Advocates say the forms do not clearly explain how to opt out of the new program.
If they take no action, the state enrolls them automatically into Cal MediConnect, a move that advocates called a violation of legal protections for people with disabilities.
The Department of Health Care Services would not respond directly because the case is ongoing but defended Cal MediConnect in a statement.
“We think the enrollment numbers reflect a wide desire among beneficiaries to get better coordinated care,” according to the statement.
The program was designed to inform beneficiaries and provide them with resources, including multiple notices and booklets that were revised numerous times at the request of advocates, according to the agency.
However, persistent confusion was evident on July 17 during the most recent of multiple teleconferences on the program with the agency’s deputy director Jane Ogle. In addition, a May 2014 survey by the Centers for Medicare and Medicaid Services found that most of those eligible for Cal MediConnect in Los Angeles County incorrectly believed their benefits would remain the same if they took no action.
“They threw this together and dropped it on top of us,” said Blane Beckwith, a quadriplegic plaintiff in the lawsuit. “Life is too difficult as it is.”
A record of problems
Beckwith planned to opt out of Cal MediConnect. But the launch is on hold in Alameda County, where he lives, until July 2015 after the state seized control in May 2014 of one of its plans, Alameda Alliance for Health, and appointed a conservator.
Even before the state could fully launch the program, the Centers for Medicare and Medicaid Services blocked one of L.A. County’s managed-care plans, L.A. Care, from automatically enrolling patients in Cal MediConnect until January 2015 because it performed poorly on Medicare’s quality assessments.
Implementation by Orange County’s health plan, CalOptima, was pushed back until July 2015 after a federal audit found serious violations that posed a “threat to the health and safety,” according to a letter from CMS.
In addition, eight of the 11 managed care plans chosen by the state have a history of denying medical services and unfair payment and billing practices that has cost them more than $4.5 million in fines since 2009, a review of enforcement actions by the California Health Report has found.
The Department of Managed Health Care, California’s HMO watchdog, fined Care 1st in May 2014 for failing to “provide continuity of care and ready referral of patients.” In 2013, the department also penalized Care 1st, one of Cal MediConnect’s San Diego County HMOs, for outsourcing claim processing to a Chinese business instead of the California company Care 1st reported as its contractor.
Anthem Blue Cross, responsible for the program in Alameda and Santa Clara counties, had the highest number of enforcement actions: just under $5 million including a $2.5 million settlement for billing violations. Also, in 2008 Blue Cross paid the largest fine ever levied by the department, $10 million, for wrongly canceling coverage after enrollees sought treatment or filed a claim. Health Net was also fined for illegally rescinding coverage.