Households caught in health-care mismatch quagmire

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This story originally appeared in The Sacramento Bee

Many Californians complain about trying to get issues resolved with Medi-Cal, the state and federal health program for the poor that now covers one-third of the state’s residents. 

Other Californians similarly complain about Covered California, the state-run health insurance exchange created under the Affordable Care Act.

Now imagine being in a family with members in each program. For those 600,000 individuals, getting and keeping insurance can be a quagmire. 

“We hear a lot from our local programs about mixed-status families getting passed back and forth” between Covered California and Medi-Cal, said Jen Flory, senior attorney at the Western Center on Law and Poverty.

While officials in both agencies say they want to help the families, the state has yet to set up an effective protocol to make that happen. In some cases, families have been able to get insurance only after going in person to a Medi-Cal office, calling Covered California from there and passing the phone to the Medi-Cal worker. 

The problem stems from the different income requirements set up under the Affordable Care Act to qualify children and parents for Medi-Cal. 

Low-income families typically would like everyone in their household to be in Medi-Cal because the program is almost cost-free. But if a family’s income is more than 138 percent of the federal poverty level, only children will qualify for Medi-Cal, and parents will need to seek insurance through Covered California, where premiums and deductibles apply. 

The family can retain Medi-Cal coverage for the children as long as the family income is 250 percent or less of the federal poverty level, about $59,000 for a family of four. 

Leona Eprem, a self-employed single mother from Chatsworth, in the San Fernando Valley, is part of one such household. 

When the health care exchange opened last year, Eprem, 47, found she qualified for a subsidized plan under Covered California, while her three teenage sons were placed in Medi-Cal.

Eprem, seeking to enroll in a subsidized plan, was told by Covered California that she needed to apply through a Medi-Cal office in her county where her children had coverage.

That was the beginning of the bureaucratic ping-pong. 

“Covered California would say things like, ‘Medi-Cal is in charge of the case, they just need to click this one box on your file,’ and the county worker would say that she could not physically click the box,” Eprem said. 

“There seemed to be a problem at every turn,” Eprem said. “And because Medi-Cal was in charge of my application, I never got to see a copy of it, so I never knew what the problem was.” 

The Medi-Cal and Covered California computer systems “are not compatible, and they do not communicate by phone or email,” Eprem said. 

Tired of relaying messages between the two agencies, Eprem went to her county Medi-Cal office in person. 

“I would call someone from Covered California when I was there so I could get them in the same room at the same time. I handed the county worker my cellphone so they could actually talk to each other,” Eprem said.

It took five trips to the county office for Eprem to finally see results.

“All in all it hasn’t been a pleasant experience,” Eprem said. 

Health insurance agents, who have been responsible for a large percentage of Covered California enrollments and help consumers navigate the process, are nearly powerless to help their mixed-coverage clients. 

“The consumers try to reach out to the county, and physically cannot get hold of anyone. It’s a ridiculous system,” said Darci Gutierrez, an agent based in Dublin.

Tony Cava, a spokesman at the California Department of Health Care Services, which oversees Medi-Cal, said, “We continue to monitor this system and work with counties to resolve issues affecting the enrollment process, including system fixes and obtaining information from applicants to verify eligibility.” 

Cava said any family with members eligible for Medi-Cal and Covered California can start the enrollment process for both programs at a county Medi-Cal office. But changes to a family’s case can come through “a number of avenues,” he said. 

His advice:

▪  Individuals updating personal information (i.e. changes of address, income, or anything that may affect eligibility) should do it through the coveredca.com Web portal or through Medi-Cal within 10 days of the change. 

▪  Changes can also be made by contacting the county or by creating an online account at http://benefitscal.com/

▪  For issues having to do with Covered California health plans, premiums or provider selection, the family must contact either the health plan or Covered California. 

▪  Changes to a Medi-Cal managed care plan, such as changing doctors, are done by contacting the plan.

Hellesen is a writer for the California HealthCare Foundation Center for Health Reporting at the University of Southern California Annenberg School for Communication and Journalism.

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