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When Lloyd Tennison moved from Walnut Creek to Stockton final yr, he assumed his protection beneath Medi-Cal, California’s safety-net medical health insurance program, can be transferred seamlessly.
About three weeks earlier than his Might transfer, Tennison known as the company that administers Medi-Cal in Contra Costa County, the place Walnut Creek is situated, 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 practically $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 “charge for service,” by which the state pays suppliers immediately 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, and so they typically invoice them immediately — 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 among every.
Touring from Walnut Creek to Stockton takes just a little greater than an hour by automotive, however so far as Tennison is worried, the 2 cities may as effectively be on reverse sides of the planet.
Tennison, 63, wanted a easy 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 practically two months for brand new ones.
“To me the entire situation 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 Services 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 Services Agency that it was the opposite method round.
They had been both wrong: 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 employees in Contra Costa processed and flagged for a June 2 switch date, mentioned Marla Stuart, director of the county’s Employment & Human Companies Division.
They set that date, Stuart mentioned, as a result of they believed Tennison might need some medical appointments in Might beneath his Contra Costa Anthem Blue Cross plan.
Medi-Cal employees in San Joaquin County, nonetheless, set a transfer date of Might 5, which overrode Contra Costa’s June 2 date and bumped Tennison from his Anthem plan for many of Might, based on Stuart.
“If anyone had known as me to confirm any of this, I undoubtedly would have instructed them Might 5 was the flawed date,” mentioned Tennison, who moved to Stockton on Might 17.
“There have been good intentions throughout,” mentioned Stuart. “It’s unlucky what occurred.”
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 known 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 Might, when he thought he was nonetheless coated by Anthem. However he wasn’t, and so they billed him immediately, regardless of signed agreements and a state regulation that prohibit billing sufferers for providers 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 Might, 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 charge for service, it theoretically ensures they’ve ongoing entry to well being care. However in follow, that’s not at all times the case.
“As a result of the state is pushing most Medi-Cal members into managed care, fewer suppliers are accepting charge 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 aren’t 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 usually communicates with its suppliers to make sure compliance with the phrases of their contracts and Medi-Cal guidelines.
Hansen is just not assured Tennison’s payments will likely be paid anytime quickly. After authorized assist attorneys sent a letter to state officers about improper Medi-Cal billing, and later met with them about it, the officers instructed them to have their purchasers submit reimbursement claims.
However 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 Might and is ready to listen to again. “Getting medical care shouldn’t be this troublesome,” he mentioned. “Right here it’s a yr later, and I’m nonetheless attempting to work this out.”
KFF Health News is a nationwide newsroom that produces in-depth journalism about well being points and is among the core working applications at KFF—an unbiased supply of well being coverage analysis, polling, and journalism. Be taught extra about KFF.
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