Calif. Families Expect State To Investigate Gold Coast Coverage Denials

Several California families are expecting state officials to hold hearings on Gold Coast Health Plan's denials of coverage for home care services for children with developmental disabilities, the Ventura County Star reports.

Gold Coast Health Plan administers Medi-Cal to more than 100,000 low-income and disabled Ventura County residents. Medi-Cal is California's Medicaid program (Kisken, Ventura County Star, 3/17).

Background

Gold Cost Health Plan was launched in 2011 as an HMO-style alternative for certain Ventura County Medi-Cal beneficiaries.

Recently, the California Department of Health Care Services requested an audit of the managed-care plan after receiving complaints about late payments and poor management.

Earlier this month, the Ventura County Medi-Cal Managed Care Commission voted to keep the audit findings confidential (California Healthline, 3/7).

Details of Coverage Denials

When Gold Coast launched in July 2011, beneficiaries already receiving coverage for home care services -- such as visiting nurse services -- received letters saying their benefits would not change.

However, some families found out in December 2011 that Gold Coast had denied coverage for such services.

According to the Star, nine families are expecting state hearings to evaluate the change in coverage policies.

The families argue that Gold Coast cannot deny coverage for the home care services because of federal regulations in the Early and Periodic Screening, Diagnosis and Treatment program for people younger than age 21. They said they have sought help from a state watchdog agency because the health plan has offered little help in locating alternative services or answering questions.

Gold Coast's Response

Gold Coast officials said that the denied coverage is for services are not considered medically necessary.

Gold Coast Health Services Director Pam Kapustay said, "A lot of these people may need assistance at home, but is it medically necessary to have a registered nurse or a licensed vocational nurse do that care?"

Health plan officials said they do not know why Medi-Cal covered the services previously. They suggested that perhaps the cases were not scrutinized before the transition to managed care.

However, Gold Coast representatives said they want to help move families into programs like In-Home Supportive Services, which provides services for the elderly and people who are blind or have disabilities. They said families also could get help at the Tri-Counties Regional Center or under the California Children's Services program (Ventura County Star, 3/17).