Advocates Want Duals Pilot Project Slowed

As the Coordinated Care Initiative prepares to launch the largest enrollment of one of its major programs, advocates for dual eligibles are asking state and federal officials to suspend automatic enrollment.

After repeatedly receiving reports that the enrollment process for Californians dually eligible for Medicare and Medi-Cal has caused scores of complications, the National Senior Citizens Law Center has called on officials at the state Department of Health Care Services and at CMS to address a “fix-it” list before pushing ahead with the transition.

“Our main recommendation is that they just slow down,” said Kevin Prindiville, executive director of NSCLC, which submitted a 27-item list of problems associated with the Cal MediConnect program to the two agencies. “We have a huge number of people moving into this new program every month and we’ve seen some problems because the system is overloaded.”

Of the 1.1 million duals in California, nearly 460,000  are targeted for the Cal MediConnect program, the state’s three-year pilot project in eight counties spearheading the new march toward coordinated care for dual eligibles. Composed mostly of low-income and elderly Californians — many with multiple chronic health conditions or mental illnesses — the duals are considered one of the most vulnerable populations in the state. Cal MediConnect began in April with voluntary enrollment in five counties — Los Angeles, Riverside, San Bernardino, San Diego and San Mateo. Four of those have also started passive enrollment and the fifth and largest county —  Los Angeles is slated to start passive enrollment July 1. The other three counties — Alameda, Orange and Santa Clara —  have not started enrollment of any kind and won’t until January 2015.

As Los Angeles County gears up for its July 1 automatic enrollment of 200,000 duals — almost half of the pilot’s entire targeted population — advocates call the numerous reports of inadequacies within the system a cause for concern.

“It’s confusing for a lot of people,” said Prindiville. “And passive enrollment is rarely a method that’s the most beneficial to patients.”

While passive enrollment is not being suspended, DHCS is working to address the problems, said DHCS spokesperson Anthony Cava in a written response to questions. Of the 27 issues raised by the seniors organization, Cava said 23 pertain to DHCS and most of them have either been resolved or were pending action.

“We recognize the challenges of our Cal MediConnect launch and enrollment schedule, but we have achieved many implementation successes by working together with our stakeholders,” wrote Cava.

To improve operations, Cava said, DHCS will be releasing a regular listing of key issues and adding new resources and layers of quality control in the system. Additionally, the department is working with CMS and stakeholders to revise processes including beneficiary testing.

CMS officials said the agency is working to ensure continuity of care and promote positive outcomes from beneficiaries. Prindiville said CMS is cooperatively working step by step to address problems as they arise. But CMS officials would not elaborate on specific measures being taken to prevent future complications.

The NSCLC list of problems included:

  • Beneficiaries improperly passively enrolled;
  • Beneficiaries already enrolled in Medi-Cal managed plans were erroneously disenrolled from Medi-Cal when they opted out of Cal MediConnect, resulting in disruption of care;
  • Beneficiaries who opted out of Cal MediConnect were passively enrolled anyway;
  • Duals improperly receiving notices that they were eligible for Cal MediConnect;
  • Duals receiving notices to enroll or opt-out without sufficient time to choose or make arrangements (beneficiaries slated for CCI enrollment in August 2014 did receive notices in May and June); and
  • Duals residing in zip codes where passive enrollment is prohibited were passively enrolled into Cal MediConnect (without receiving notices).

The biggest concern is continuation of care during the massive, complicated transition to CCI, advocates said. Not only are beneficiaries overwhelmed with the new set of choices to make regarding selecting a health care provider or plan, many do not even understand that they have the choice to opt out of the plan entirely, advocates said. Additionally, they pointed out not all current providers are participating in Cal MediConnect, a fact that passively-enrolled beneficiaries might not realize until it’s too late.

“In the worst-case scenarios, we’ve had reports of people missing surgeries or other important doctor visits because they didn’t know about the change in their plan,” said Prindiville. “These things pop up at the point of service.”

A major test will come on July 1 with the start of Los Angeles County passive enrollment.

“On the horizon, we need to see the state committed to improve notices, make them more understandable and give patients the time to make a choice,” said Prindiville. “We hope that there is no problem, but that’s the big test.”

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Capitol Desk Medi-Cal Medicare