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Obamacare’s Other Story: Medi-Cal Has Its Own Glitches

State officials have been crowing that more than 400,000 Californians have enrolled in plans through the state’s health insurance exchange, Covered California.

However, another important statistic is getting lost in the exchange hubbub, and it has to do with Medi-Cal, the state’s publicly funded Medicaid program that insures low-income residents.

Medi-Cal is huge. In previous columns, I described it as serving more than 8 million Californians.

That was so 2013.

Under Obamacare, Medi-Cal broadened its eligibility on Jan. 1, opening the program to more Californians, including childless adults, who previously were ineligible.

How many people have enrolled so far under the expansion? The state Department of Health Care Services, which administers Medi-Cal, hasn’t been terribly forthcoming with the answer.

But it did say this when I asked: “Current Medi-Cal enrollment is nearly 9.2 million.”

Um … excuse me?? That means about one in four Californians is on Medi-Cal. That also means Medi-Cal is not just huge, but ginormous.

Clearly, people are making it through the enrollment process. But like the folks who have wrestled with the Covered California website or waited on hold for hours without getting an answer to their question, some Medi-Cal applicants say they are hitting roadblocks that are preventing them from obtaining coverage.

And I’m hearing from them. A lot of them.

Today, I’m going to explain what you can do if you get tripped up in the Medi-Cal application process.

And remember, there’s no open-enrollment period for Medi-Cal like there is for Covered California and the open market. You can apply for Medi-Cal anytime.

Q: I applied for health insurance on the Covered California website, and I was directed to apply for Medi-Cal.

I went to the Medi-Cal website and completed their questions electronically. But I was denied based on traditional eligibility guidelines: I’m not pregnant, not under 21, not a family with a child, not blind or disabled, and under 65. What’s going on?

A: I wish I could give Michael from Clovis a definitive answer, but I can’t. I don’t have enough information to say whether he’s newly eligible for Medi-Cal or not.

But that’s not really the point. I have received numerous emails from others who also think they have been denied Medi-Cal because they’re being subjected to the old (pre-January) eligibility criteria.

Under the expansion, some key enrollment criteria have changed. The income threshold to qualify for Medi-Cal went up to 138 percent of the Federal Poverty Level (FPL). Last year, that computed to about $15,800 for an individual and $32,500 for a family of four. (The 2014 FPL guidelines have yet to be released.)

And, as I’ve already mentioned, the program is now also open to childless adults.

There are other changes that affect eligibility that I won’t get into here. Suffice it to say, lots of Ask Emily readers think they’re eligible under the new guidelines, but they’re getting denied.

These include people who have applied online as well as those who applied through their county social services agencies, which determine Medi-Cal eligibility.

Now what should they do? State officials maintain that you’ll get the right answer by contacting your county directly.

(You can find contact phone numbers for your county’s social services agency on the DHCS website or by clicking the “Find Local Help” button on the Covered California home page.)

County Medi-Cal workers have been trained in the new rules, says Tony Cava of DHCS. They “can sit down with people and ensure eligibility questions are understood and accurately answered,” he says.

And we will all live happily ever after.

If only. Some Ask Emily readers tell me that it was precisely county workers who denied them coverage or couldn’t help with the new eligibility criteria.

One was Yvette of East Los Angeles, who says she is “mystified and dumbfounded” by a social worker’s denial.

“I’m hoping you could give me some pointers as to how I can appeal or fight her decision,” she adds.

Will do.

Q: Is there anything else I can do if I believe I was incorrectly denied Medi-Cal coverage?

A: Yes. Appeal the decision.

When you receive your denial letter, there will be directions on how to appeal, says Cava.

You really should do so if you believe you were wrongly denied, says Jen Flory, senior attorney at the Western Center on Law & Poverty.

Flory confirms that there have been problems as Californians have tried to apply for the expanded Medi-Cal program. Most complaints come from people who applied through the Covered California website, she says.

“People have gotten some notices that have confusing information,” she says. “One said something like, ‘You may be eligible for Medi-Cal, but here’s how you pick your Covered California plan’.”

If you’re planning to appeal, you have to do so within 90 days. Once you do, you are entitled to a hearing within 45 days, she says.

However, people often avoid hearings because they “are able to resolve the issue with a county worker ahead of time,” she says.

If you do end up at a hearing, you generally will receive a decision within a month.

Sounds like fun, doesn’t it? Luckily help is available. Flory points to the Health Consumer Alliance website: The alliance offers programs across the state that can assist you.

Good luck.

Provided by the Center for Health Reporting at the University of Southern California.

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