When Lloyd Tennison moved from Walnut Creek to Stockton final yr, he assumed his protection below Medi-Cal, California’s safety-net medical health insurance program, could be transferred seamlessly.
About three weeks earlier than his Could 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 crimson tape, disrupt his care, and saddle him with two payments totaling almost $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 briefly from managed care insurance policy into conventional Medi-Cal, also called “payment for service,” during which the state pays suppliers immediately for every service rendered. However managed care practitioners who don’t take part in conventional Medi-Cal don’t have any solution to receives a commission once they see such sufferers, and so they typically invoice them immediately — although 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 industrial well being plans, that are paid by the state to handle the care of Medi-Cal sufferers. Many have considered one of every.
Touring from Walnut Creek to Stockton takes a bit of greater than an hour by automobile, however so far as Tennison is anxious, the 2 cities would possibly as properly be on reverse sides of the planet.
Tennison, 63, wanted a easy well being care transition. With extreme persistent ache in his again, shoulders, and neck, he requires common bodily remedy and monitoring by an orthopedist, in addition to a number of ache medicines. He additionally has carpal tunnel syndrome and Sort 2 diabetes.
Due to miscommunication and confusion surrounding his transfer, a number of bodily remedy appointments he’d made for June 2022 have been canceled, and he needed to wait almost two months for brand spanking new ones.
“To me the entire problem is the confusion,” Tennison mentioned. “Proper hand and left hand, no person talks to one another, and no person talked to me.”
The primary trace of hassle got here when he known as Contra Costa County Employment & Human Providers in late April 2022 to report his upcoming transfer and was advised the brand new county needed to provoke the switch — solely to listen to from a employee at San Joaquin’s Human Providers Company that it was the opposite means round.
They have been each incorrect: 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 staff in Contra Costa processed and flagged for a June 2 switch date, mentioned Marla Stuart, director of the county’s Employment & Human Providers Division.
They set that date, Stuart mentioned, as a result of they believed Tennison might need some medical appointments in Could below his Contra Costa Anthem Blue Cross plan.
Medi-Cal staff in San Joaquin County, nevertheless, set a transfer date of Could 5, which overrode Contra Costa’s June 2 date and bumped Tennison from his Anthem plan for many of Could, in keeping with Stuart.
“If anyone had known as me to confirm any of this, I positively would have advised them Could 5 was the incorrect date,” mentioned Tennison, who moved to Stockton on Could 17.
“There have been good intentions throughout,” mentioned Stuart. “It’s unlucky what occurred.”
Being reduce 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 Workplace 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 Could, 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 legislation that prohibit billing sufferers for providers coated by Medi-Cal.
The payments caught Tennison unexpectedly, as a result of the ombudsman had advised him in early June that he had nonetheless been on Anthem by way of Could, 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 briefly in payment 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 payment for service,” mentioned Hillary Hansen, an lawyer with Authorized Providers 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 usually are not 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 frequently communicates with its suppliers to make sure compliance with the phrases of their contracts and Medi-Cal guidelines.
Hansen shouldn’t be assured Tennison’s payments might be paid anytime quickly. After authorized assist legal professionals despatched 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 usually can’t afford that, Hansen mentioned.
Tennison submitted his reimbursement type in Could and is ready to listen to again. “Getting medical care shouldn’t be this tough,” he mentioned. “Right here it’s a yr later, and I’m nonetheless making an attempt to work this out.”
