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August, 1997
Written by the Consumers Union West Coast Regional Office.
California is switching 3.4 million Medi-Cal consumers from fee-for-service Medi-Cal or "regular" Medi-Cal into a managed care system. Twelve counties are included in this managed care system which is called the "Two-Plan Model." Under the Two-Plan Model each county will have two health plans for beneficiaries to choose from. The two plans are called a "Local Initiative" (a county organized plan which includes the local safety net providers and clinics) and a "Commercial Plan" (a private plan like Blue Cross' California Care). Fresno County is different; it has two commercial plans.
The twelve counties included in the Two-Plan Model are Alameda, Contra Costa, Fresno, Kern, Los Angeles, Riverside, San Bernardino, San Francisco, San Joaquin, Santa Clara, Stanislaus, and Tulare. Counties are at different stages of implementing the Two Plan Model. For the current status of each county and the names of the plans operating in that county, turn to page 9.
Women and children on AFDC (Aid to Families with Dependent Children) now called TANF (Temporary Assistance to Needy Families) and medically indigent children must participate in managed care. They are called the "mandatory enrollment group." They are or will be required to enroll in managed care once the Two-Plan Model is fully implemented in their county. There are, however, exceptions. If a Medi-Cal consumer falls into either of the following two categories she may remain in regular Medi-Cal:
1. She is American Indian or lives in an American Indian household and prefers to receive health services at an Indian Health Center. (The consumer must have her doctor fill out an Indian Health Program Exemption Form);
2. She is receiving treatment for a serious medical condition from a doctor who is not a part of either the Local Initiative or the Commercial Plan. Serious medical conditions may include pregnancy, HIV/AIDS infection, diabetes, cancer, high blood pressure, heart disease, asthma, tuberculosis, etc. There is no official list of what constitutes a serious medical condition, so if a consumer believes that her condition would qualify, she should make a request to remain in managed care. (The consumer must have her doctor fill out a Medical Exemption Form).
A child who receives health services from California Children's Services (CCS) also is required to enroll in a managed care plan. The child will continue to receive CCS related health services outside the plan but she will have to receive routine health care through her managed care health plan.
Consumers such as the elderly, blind, and disabled (those on SSI) are in a voluntary enrollment group. They are not required to enroll in managed care, but may voluntarily enroll if they choose to do so.
Foster children and children in relative foster placements are not required to enroll in managed care, yet the state has mistakenly sent enrollment forms to the homes of many foster children.
Medi-Cal consumers are not required to enroll in a managed care health plan until both the Commercial Plan and the Local Initiative are operational in their county. In most counties one plan is up and running before the other. During this time, a consumer may remain in regular Medi-Cal, or she may join the one health plan that is operating in her county. Once both plans are up and running she still has the option to switch to the new health plan or remain in her current health plan.
Under regular Medi-Cal, consumers can choose their doctor and can go directly to the particular kind of doctor they want or need. Under the managed care system consumers can only go to those doctors who are a part of their plan and they must either choose or be assigned to one main doctor. This doctor, called a primary care physician, must approve all treatment and referrals to any other doctors. Additionally, under regular Medi-Cal, doctors are paid per doctor visit or per service. Under the managed care system, health plans are paid a flat rate per patient, per month, no matter how frequently or infrequently they see a patient.
Due to the transition to managed care, consumers may have trouble finding providers who will continue to treat them under regular Medi-Cal. At the same time, consumers may find it difficult to access health care under the managed care system due to unfamiliarity with the process.
Maximus (Health Care Options) is responsible for enrolling (signing up) consumers in a health plan. Maximus is the company that was hired by the state to be the Health Care Options contractor. The job of the Health Care Options contractor is to educate Medi-Cal consumers about the Two-Plan Model and to assist consumers enroll in one of the plans. The telephone number for Health Care Options is 1-800-430-4263 or TDD (for the hearing impaired) 1-800-430-7077.
Health Care Options is responsible for sending consumers information packets explaining that they must choose a health plan, what health plans they can choose from, and that if they do not choose a health plan in 30 days, one will be chosen for them. When Health Care Options chooses a health plan for the consumer, this is called default or "automatic assignment" (note that in Los Angeles all defaults have been temporarily stopped at least until January, 1998). Many consumers have been defaulted because they either did not receive this information packet, did not understand the packet because they received the packet in English and they speak another language, or submitted an incomplete enrollment form. Many others were defaulted due to administrative and processing errors. If a consumer has been defaulted into a health plan they can always disenroll from that health plan and enroll in the other plan. See page 4-5 -- Disenrollment Rights, for more information. The information packet is available in the following languages: English; Spanish; Armenian; Cambodian; Farsi; Russian; Hmong; Vietnamese; Chinese; and Loa. Consumers should call Health Care Options at 1-800-430-4263 if they need a packet in one of these languages. The original information packet was recently revised and simplified and should be available by November, 1997.
Health Care Options also will give presentations to explain the enrollment process and answer questions. Some consumers found the presentation to be too lengthy so Health Care Options recently produced an eight minute videotape which explains the enrollment process. The videotape is currently available in English. It will soon be available in: Spanish; Armenian; Cambodian; Farsi; Russian; Hmong; Vietnamese; Chinese; and Loa. To find out more about viewing the videotape or attending a presentation, consumers should call Health Care Options at 1-800-430-4263.
Consumers must choose a primary care physician (doctor) who is a member of the plan they choose. A primary care physician is the doctor who will coordinate the member's health care. A primary care physician is sometimes referred to as a gatekeeper because they must make or approve all necessary referrals to other doctors, specialists or services before a consumer can receive these services. Consumers may choose a general practitioner, a family doctor, a pediatrician or an obstetrician/gynecologist as their primary care physician.
Once a consumer is enrolled in a plan she has another 30 days to choose her doctor. If she does not choose one, the health plan will choose one for her. If the plan chooses a doctor for the member, the plan must inform the member that they have done so within 10 days.
Yes. Consumers always are entitled to switch from one doctor in a plan to another doctor in that plan. The plan must process these requests within 30 days. This should be done by calling the health plan's toll free number.
Enrollment forms are currently available in doctors offices during the initial transition period (except in Kern County where the state pulled all enrollment forms from doctors offices due to marketing abuses). Allowing doctors to have enrollment forms in their offices is a temporary measure implemented by the Department of Health Services (DHS) to help increase enrollment and avoid the high rate of default that is occurring in many counties. Enrollment forms should be removed roughly three months after "conversion" occurs. Conversion has occurred once both plans in a county are up and running and all new members have been notified of their enrollment. Although this measure may decrease the default rate it creates potential problems for consumers. First, Health Care Options is required to inform consumers of their health care options in a neutral manner. If enrollment ends up occurring through doctors offices then consumers do not benefit from this neutral presentation of information. Second, provider enrollment creates the potential for marketing abuses. Examples of marketing abuses would be if a doctor or her staff: makes negative references to one plan; fills out the enrollment form for the consumer; or tells the consumers to enroll in one plan over the other because they are paid more by that plan. Doctors are, however, allowed to tell consumers which plan they are affiliated with. Any marketing abuses should be documented by the consumer and reported to their local legal services office, consumer representative, and/or the Ombudsperson at the Department of Health Services. The number for the Ombudsperson is 1-888-452-8609. For a list of legal services offices turn to page 10-11.
Members have the right to disenroll from one health plan and enroll in the other for any reason. This is done by calling Health Care Options at 1-800-430-4263 and filling out a disenrollment form. The same form is used for both enrollment and disenrollment, however, some provider offices have a separate disenrollment card. It may take Health Care Options up to 45 days to disenroll a member. Until the member receives a letter stating that she is officially disenrolled she must continue to receive health services at her old health plan.
In case of an emergency Health Care Options must process a disenrollment/enrollment request within two working days. Examples of emergency disenrollments include:
1. when a member needs health care that is not covered by her plan;
2. the member is a child receiving services under the Foster Care/Adoption Assistance Program;
3. the member has inadvertently been assigned to both plans;
4. the member is incarcerated; or
5. the member needs long term health care.
To help expedite disenrollment requests the health plan should fax the disenrollment request to Health Care Options. There have been many problems getting emergency disenrollments processed in a timely manner. If a consumer finds that her plan or Health Care Options is exceeding the two day time limit for emergency disenrollment she should report the problem to the Ombudsperson at the Department of Health Services. The number again is 1-888-452-8609.
Members are entitled to access/receive health care services in their preferred language through 24-hour access to interpreters (if they speak one of the following languages: Spanish; Armenian; Cambodia; Farsi; Russian; Hmong; Vietnamese; Chinese; Korean; or Loa). This includes providing interpreters for language and signage translations.
Each plan is required to maintain a 24-hour multilingual telephone contact number for handling emergencies.
Members also are entitled to access/receive health care services in a way that they feel is culturally appropriate.
Members are entitled to receive written notice if a health plan denies or modifies a medical service. The written notice must also explain the reason for the denial. For an explanation on how to challenge a denial see below -- Member Complaints or Problems.
Members are entitled to be informed if their plan makes any changes in the medical services which will be provided by the plan.
Members are entitled to be informed in writing of the plan's grievance procedures and the members right to a fair hearing. For more information on grievance procedures and fair hearings, see below -- Member Complaints or Problems.
Members are entitled to a toll free number for their health plan.
Members' medical information and records are to be kept confidential.
If a member is under age 3 and is developmentally delayed she is entitled to be referred to an Early Start Program by her health plan and doctor.
Members are entitled to an initial health assessment within 120 days of enrollment (approximately 4 months) unless a doctor considers their medical record complete.
A member should not have to travel more than 30 minutes or more than 10 miles from her home to see her doctor.
What should a member do if she is having problems with her health plan?
A member has several options. She can:
1. call her health plan and ask for assistance in resolving the problem;
2. call the Ombudsperson at the Department of Health Services to have her complaint investigated and resolved. The number again is 1-888-452-8609;
3. file a formal grievance with her plan (see page 7);
4. file for a state fair hearing. This is the only option which allows the member to continue receiving medical treatment or "aid-paid-pending," (see page 8);
5. file a formal grievance and file for a state fair hearing at the same time; or
6. disenroll from the health plan and enroll in the other health plan.
A grievance is a formal complaint filed by a member when she is experiencing problems with her health plan or has a complaint regarding the quality of her health care. A grievance is filed with the member's health plan and is addressed or resolved by the health plan. No independent party is involved in this process so the member may be at a disadvantage.
Each health plan is required to have an established grievance procedure.
Members are entitled to be informed in writing of their plan's grievance procedures within 7 days of enrolling in the plan.
Members are entitled to file a grievance form in their preferred language.
Members are entitled to file a grievance verbally or in writing.
Members are entitled to the assistance of the Ombudsperson at the Department of Health Services to help with their grievance. The number again is 1-888-452-8609.
The plan must respond within 5 days of receiving a grievance to tell the member that her grievance has been received and who she should contact to follow up on her grievance.
Grievances shall be resolved within 30 days. If a grievance cannot be resolved in 30 days, members are entitled to be notified in writing of an estimated completion date for their grievance.
A plan cannot refuse to fill a drug prescription while a member is disputing whether or not the plan will cover the prescription.
A fair hearing is different from a grievance in that a fair hearing request is filed with the State, not with the health plan. This allows the member to have her case heard by a neutral party. A fair hearing is an informal proceeding conducted by a hearing officer who will evaluate the positions of both the member and the health plan and determine weather the health plan has acted properly.
To file for a state hearing and obtain a fair hearing form consumers should call the Department of Social Services at: 1-800-952-5253 or TDD (for the hearing impaired) 1-800-952-8349.
Members are entitled to be informed in writing, by their plan, of their right to a fair hearing.
If a member files for a hearing within 10 days of receiving notice of a discontinued or modified health service and she is currently receiving medical treatment for some condition, the member is entitled to aid-paid-pending. This means that a member's medical treatment must continue, without interruption, until she receives a fair hearing decision.
By submitting a grievance a member does NOT waive her right to a fair hearing. Both options are available and can be pursued at the same time.
If a member is going to file for a fair hearing she must do so within 90 days of the date a service was denied, delayed, or stopped.
The Department of Social Services must set a hearing date within 30 days of a member's request and must give the member notice of the date of the hearing at least 10 days before the hearing date.
Members are entitled to an impartial hearing officer who is not affiliated with any health plan or any doctors.
Members are entitled to receive a final decision within 90 days from the date they filed their fair hearing request.
LOCAL INITIATIVE
COMMERCIAL PLAN
COUNTY
START UP DATES
START UP DATE
Alameda
Alameda Alliance for Health
1/1/96
Blue Cross
7/1/96
Contra Costa
Contra Costa Health Plan 2/1/97
Foundation Health
3/1/97
Fresno
No Local Initiative
(2 commercial plans)
Blue Cross - 11/1/96
Foundation Health- 1/1/97
Kern
Kern Family Health Care
7/1/96
Blue Cross
9/1/96
Los Angeles
LA Care - 4/1/97 Plan partners include Blue Cross, Care 1st, Maxicare, Tower Health Services, United Health, and Community Health
Foundation Health
Expected start date: 7/1/97
Default enrollment has been delayed in Los Angeles till January, 1998.
Riverside
Inland Empire Health Plan
9/1/96
Molina
UNKNOWN
San Bernardino
Inland Empire Health Plan
9/1/96
Molina
UNKNOWN
San Francisco
San Francisco Health Plan
1/1/97
Blue Cross
7/1/96
San Joaquin
Health Plan of San Joaquin
2/1/96
Omni
2/1/97
Santa Clara
Santa Clara Family Health Plan - 2/1/97
Blue Cross
10/1/96
Stanislaus
Blue Cross
estimated start date: 10/1/97
Omni
2/1/97
Tulare
Medico
estimated start date: 4th quarter 1997
Foundation Health
estimated start date: 4th quarter 1997
August 27, 1997
LIST OF LOCAL LEGAL SERVICES OFFICES
Alameda
Berkeley Community Law Center
3130 Shattuck Avenue
Berkeley, CA 94705
(510) 548-4040
Legal Aid Society of Alameda County
Oakland Office
510 16th Street, #400
Oakland, CA 94612
(510) 451-9261
Legal Aid Society of Alameda County
Hayward Office
22531 Watkins Street
Hayward, CA 94541
(510) 538-6507
Contra Costa
Contra Costa Legal Services Foundation
Richmond Office
1017 Mac Donald Avenue
Richmond, CA 94801
(510) 233-9954
Contra Costa Legal Services Foundation
Pittsburg Office
1901 Railroad Ave., Suite D
Pittsburg, CA 94565
(510) 439-9166
Fresno
Centro La Familia Advocacy Service, Inc.
2014 Tulare Street, 7th Floor
Fresno, CA 93721
(209) 441-1611
Central California Legal Services, Inc.
2014 Tulare, #600
Fresno, CA 93721
(209) 441-1611
Kern County
Greater Bakersfield Legal Assistance, Inc.
615 California Avenue
Bakersfield, CA 93304
(805) 325-5943
Channel Counties Legal Services
132 S "A" Street
Oxnard, CA 93032
(805) 487-6531
Los Angeles
Legal Aid Foundation of Los Angeles
East Los Angeles Office
5228 Whittier Blvd.
Los Angeles, CA 90022
(213) 266-6451
Legal Aid Foundation of Los Angeles
Greater Watts Justice Center
3406 W. Washington Blvd.
Los Angeles, CA 90018
(213) 732-0843
Legal Aid Foundation of Los Angeles
South Central Office
9601 South Broadway
Los Angeles, CA 90003
(213) 971-4102
Legal Aid Foundation of Los Angeles
Eighth Street Office
1550 West 8th Street
Los Angeles, CA 90017
(213) 487-7609
Legal Aid Foundation of Los Angeles
1102 South Crenshaw Blvd.
Los Angeles, CA 90019
(213) 964-7950
San Fernando Valley Neighborhood Legal Services
13327 Van Nuys Blvd.
Pacoima, CA 91331
(818) 834-7570
August 27, 1997
Riverside
Inland Counties Legal Services
1120 Palmyrita Ave., Suite A
Riverside, CA 92507-1705
(909) 683-7108
Inland Counties Legal Services
Indio Branch Office
45-550 Grace Street
Indio, CA 92201
(760) 342-1591
San Bernardino
Inland Counties Legal Services
Rancho Cucamonga Office
10601 Civic Center Dr., #260
Rancho Cucamonga, CA 91763
(909) 980-0982
Inland Counties Legal Services
San Bernardino Office
570 W. 4th Street, #104
San Bernardino, CA 92401
(909) 884-8615
Inland Counties Legal Services
Victorville Branch Office
14196 Amargosa Rd., Ste. K
Victorville, CA 92392
(619) 241-7073
San Francisco
San Francisco Neighborhood Legal Assistance Foundation
225 Bush Street, 7th Floor
San Francisco, CA 94104
(415) 982-1300
San Joaquin
California Rural Legal Assistance, Inc.
Stockton Office
242 North Sutter Street, #411
Stockton, CA 95202
(209) 946-0605
Santa Clara
Community Legal Services
480 N. First Street
San Jose, CA 95112
(408) 283-3700
Legal Aid Society of Santa Clara County
480 N. First Street
San Jose, CA 95103-0103
Stanislaus
California Rural Legal Assistance
1020 15th Street, #11
Modesto, CA 95354
(209) 577-3811
Tulare
Tulare Kings County Legal Services
208 W. Main St., Suite U-1
Visalia, CA 93291
(209) 733-8770
