With a New Complaint Phone System, Will Medi-Cal Enrollees Be Able to Get Help?


When one of the millions of people enrolled in California’s low-income health program has a complaint or needs help, there’s a number they can call.

But for more than a year, that phone line was unreliable — tens of thousands of calls went unanswered.

In June, the California State Auditor found that the ombudsman phone system for the managed care Medi-Cal program was severely deficient and urged officials with the Department of Health Care Services to make upgrades. Between February 2014 and January 2015, an average of 12,500 calls went unanswered each month, the audit revealed. Some months, the telephone system rejected as many as 45,000 calls.

The department launched part of an upgraded phone system on Sept. 30 and plans to roll out additional features later this month.

Although the agency says the system will improve data collection, reduce dropped calls and allow people to leave messages, advocates question whether the office will have enough staff members to respond to the complaints once it receives them.

I look forward to seeing some of the data that comes out from the new phone system, but I don’t think the current staffing is sufficient to address current demands,” said Linda Nguy, legislative advocate for the Western Center on Law and Poverty. “We think there needs to be additional resources.”

The department contends that it has enough staff members to respond to calls. “We believe that we have the right processes and sufficient resources (employees) in place to staff the phone lines appropriately,” said spokeswoman Carol Sloan.

Enough employees?

The Office of the Ombudsman has 24 employees, the same number it has had since 2014. According to the audit, “The chief of the ombudsman office stated that staffing limitations have allowed it to answer an average of just 30 percent to 50 percent of the calls that the telephone system has accepted.”

It seems unlikely, Nguy said, that as the upgraded system begins accepting more calls, the office will be able to respond to them all, when it hasn’t been able to handle the current volume.

Enrollment in Medi-Cal has surged since January 2014, when the federal Affordable Care Act expanded the low-income health program. Medi-Cal enrolls more than 12.5 million people — about a third of the state’s population.

More than 78 percent of Medi-Cal enrollees are in a county-based health plan called managed care. Managed care is a system where enrollees have a list of doctors they can select to see within their network.

There are now 9.8 million people enrolled in managed care plans in California, almost 4 million more than in Dec. 2013, before health care reform opened the gates to Medi-Cal.

The state doubled the number of employees in the ombudsman office between 2013 and 2014, up to the current number of 24. But over the last year, as the number of people enrolled in Medi-Cal managed care has continued to swell, the number of workers in the complaint office has stayed constant.

Patients wait for answers

This year’s state budget included funding to make nine positions in the Office of the Ombudsman permanent, instead of temporary, but the money didn’t actually increase the number of people working in the office, Sloan said.

In 2014, the Health Care department sent nine employees who were previously working in another part of the agency to work in the ombudsman office. This year’s budget money allowed the office to hire nine new employees and send the temporary workers back to the original jobs in the department.

Initially advocates believed the funding for the nine positions would result in an increase in staffing, and they supported it during the budgeting process, while still questioning whether it was enough. When it became clear in June that the funding wouldn’t result in more employees in the office, they were disheartened, Nguy said.

“Initially we wondered if adding that nine was even sufficient, so to discover that it was only replacing existing staff — that didn’t resolve the concerns,” she said.

It’s important that the department have enough employees to respond to calls and emails because sometimes people call with critical medical needs.

When managed care Medi-Cal enrollees move to a different county, for example, they can call the ombudsman and be quickly un-enrolled in their former county and enrolled in their new county, Nguy said.

“This is especially important if the beneficiary is undergoing cancer treatment or other medically necessary treatment,” she said. “Otherwise, this disenrollment/enrollment process could take months.”

In the case of patients with cancer or who are in need of medication, that’s time they may not have.

The ombudsman office can also help patients if their managed care plan says a treatment isn’t covered when in fact it should be, or if an enrollee has a disagreement with the plan.

Oversight questioned

The new phone system allows the ombudsman office to take more calls, indicates callers’ place in line and gives them the option of staying on the phone or receiving a call back. The system also has more Spanish-language options.

The new system is expected to have a capacity to handle 500 calls at a time, up from the previous 30.

Data on the calls and emails will be stored online, and the system will measure the demand for services, number of abandoned calls and the wait time, according to a Health Care department July briefing.

DHCS says it monitors the ombudsman data, but it is unclear how that data is being used, who has access to it and how frequently it is checked by anyone outside the ombudsman office.

Nguy said she hopes the increase in data collection under the new system will show the need for additional staff members to respond to questions and complaints.

“There’s still the same number of people working the system so that doesn’t mean people will necessarily get help sooner,” she said. “It might mean that they (the ombudsman office) will be able to get to you eventually, but the line may just get longer and longer.”

To contact the ombudsman office, call 1-888-452-8609 between 8 a.m. and 5 p.m. Mondays through Fridays, excluding holidays, or send an email to MMCDOmbudsmanOffice@dhcs.ca.gov.

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