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Advocates Say State Cooperating With Possible Revamp of Notices to Duals

Advocates for seniors and the disabled expressed both relief and continued concern over the weekend about the state’s approach to its May 1 launch of half of the counties in the duals demonstration project Cal MediConnect, a central component of the state’s Coordinated Care Initiative.

Following a group letter by advocates that raised concerns about the notices being sent to dual-eligible beneficiaries — particularly over the inability of blind or visually impaired duals to understand their choices in the transition — advocates said state officials at the Department of Health Care Services have responded with a willingness to alter their notices to meet some of the concerns.

“The department has said they’re willing to sit down and fix some of this,” said Amber Cutler, staff attorney in the Los Angeles office of the National Senior Citizens Law Center, a not-for-profit advocacy group that was one of the signatories on the letter to DHCS and CMS.

“When the 60-day notices went out [March 1], we thought those were totally inadequate,” Cutler said. “All the language and messaging was inconsistent and confusing. The department has said they’re open to changing the messaging, at least in the 60-day notices to come. And hopefully make some changes to the choice form.”

DHCS Director Toby Douglas said working with stakeholders has always been a key component of the duals project.

“There is no question that getting input from the community and working together ultimately means a better Cal MediConnect,” Douglas said in a written statement. “We’ll continue to do so as we work toward a better system of care for our dual-eligible population.”

Dual-eligibles are Californians eligible for Medi-Cal and Medicare. The demonstration project is the state’s eight-county plan to enroll duals in Medi-Cal managed care that combines the finances and services of both programs. The hope is that seniors and the disabled will get better care and more services through integration of that care. Coordinating care and melding finances may save money, as well.

Advocates say the main problem with notices to beneficiaries is that they’re confusing and they don’t make it clear that duals have a choice of opting out of the demonstration project.

“Right now, they could look at this choice form and choose all of the boxes,” which would invalidate their choices, Cutler said. “And if you want to opt out, the ones in Medi-Cal managed care would have to choose the Medi-Cal managed care plan they’re already in. That’s a confusing choice.”

State officials have been adamant that it won’t have an opt-out form, or even a check-box that says the words, “opt out,” and Cutler said that’s understandable, to some degree.

“It doesn’t test well [with beneficiaries], because [many of them] can’t opt out of the whole thing,” Cutler said. For many of them, she said, “You can only opt out on the Medicare side, so I understand why you wouldn’t want that [as one of the beneficiaries’ choices].”

For many months and even years, advocates and state officials alike have used the words “opt out” when talking about beneficiaries’ choices, so not seeing those words on the choice form are a red flag to advocates, she said.

Cutler would like a simple explanation of the choices, laid out like a decision tree, so people who are enrolled in Medi-Cal managed care plans know their choices, and those who aren’t know theirs, as well.

“It should be something that makes it clear what choices you’re making. The notices themselves need to do a good job of explaining,” Cutler said. “We think there are some simple fixes, but there are also some substantive changes that could be made.”

The other major concern laid out in the advocates’ letter is that people who are blind or visually impaired are at a disadvantage in understanding what’s happening and making choices, according to Ron Elsberry, a senior staff attorney at Disability Rights California.

“This is a population that is elderly, fragile and disabled, so we know there are a lot of people who are visually disabled in this group,” Elsberry said.

According to DHCS statistics, 37% of people eligible for the Coordinated Care Initiative are “blind/disabled,” so Elsberry said it’s important to have alternate materials for those people — in Braille or in audio format for the blind and in large-print type for the visually impaired. Those materials are available, but they need to be requested.

“The problem is, when these notices go out, people who are blind don’t know they’re receiving them,” Elsberry said. “Mail accumulates and occasionally people check it for them. They don’t even know they can request anything.”

More important, he said, is that visually impaired people have to request an alternate form every time.

“So one of the most important things is to have an identifier with each person who requests it. That way the information could be automatically sent that way,” Elsberry said.

“The whole point [of the duals demonstration project] is this is a person-centered program,” Cutler said. “The place that has to happen is the choice. You want the beneficiaries to know about the choices.”

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