Judge Rules on Medi-Cal Backlog Suit, Orders State To Adhere to 45-Day Deadline

On Thursday, an Alameda County Superior Court judge issued a preliminary injunction requiring the state to adhere to a 45-day limit for processing Medi-Cal applications.

The ruling by Judge Evelio Grillo was a victory for health care advocates in a lawsuit over the state’s extensive backlog in processing Medi-Cal applications. The Medi-Cal expansion and the first open enrollment period for Covered California brought millions of applications to the door of the Department of Health Care Services, which oversees Medi-Cal.

Computer issues hampered the processing of many of those applications, and in March 2014 the backlog of unprocessed claims peaked at more than 900,000 applications. It took many months to clear the bulk of those applications. Some of them are still hanging fire almost a year later, said Jen Flory, senior attorney in the Sacramento office of the Western Center on Law and Poverty.

“They’ve been working on it, but it’s not complete. There are large numbers of people they’re still processing, and different counties are reporting different numbers,” Flory said. “From our perspective, anytime there’s even one person where services are withheld, that’s a problem. The number is down, but I would need to see the number zero.”

DHCS officials said the ruling simply reflects changes already made at the department, where recent applications have been processed within the 45-day limit.

“That action, along with other extensive efforts undertaken throughout 2014, has virtually cleared the number of pending individuals, reducing it by more than 95%,” department officials said in a written statement.

Doing the math from the peak of 900,000 unprocessed applications, that leaves roughly 45,000 applications still pending from 10 months ago.

That remaining backlog dismays Lucy Quacinella, founder of Multiforum Advocacy Solutions, a private legal firm in San Francisco. Quacinella was lead attorney in the lawsuit.

“This ruling is very significant,” Quacinella said. “The state made some improvements that never would have happened without the lawsuit. We would absolutely be looking at a growing backlog right now.”

Quacinella said the state now must clear those final pending applications.

“The ruling requires the department to complete eligibility reviews and give a final decision,” she said. “And if the state is unable to do that, they have to grant preliminary eligibility to those who are likely eligible.”

DHCS officials said that’s happening right now.

“DHCS is processing the remaining pending applicants this week,” DHCS officials said in their written release, “and once all needed verifications of information are complete, eligible individuals will be moved into coverage.”

It has been a complicated and thorny problem, the statement said.

“There are multiple factors affecting DHCS’ ability to process individuals into coverage, including the need to receive documents from applicants to verify eligibility, as well as some technology issues,” the statement said. “Of the remaining pending applications, many are individuals who have not yet provided information needed to verify their eligibility, and many others are duplicate applications that will be removed from the system.”

The second open enrollment period for Covered California started Nov. 15, 2014, and runs through Feb. 15. That effort impacts Medi-Cal, because many Covered California applicants, if they look like they might be eligible for Medi-Cal, are referred to DHCS. That big bump in Medi-Cal enrollment applications has gone smoothly this time around, DHCS officials said.

“Importantly, improvements to our system have resulted in immediate enrollment for more than 80% of new applicants found eligible for Medi-Cal,” the DHCS statement said. “We are committed to complying with any court orders and to further improving this process so that all individuals who qualify for coverage can be enrolled in Medi-Cal as quickly as possible.”

Advocates praised DHCS for that instant enrollment success.

“Instant enrollment makes us all happy,” Flory said. “They have taken some steps to avoid the backlog, and that’s something. They were voluntary steps. Now it’s required.”

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