SAN BERNARDINO, Calif.--Like thousands of other low-income Californians, Lana Grissom wasn’t elated about the state’s new Cal MediConnect (CMC) health care program, despite its promise of smoother sailing for patients long bounced from one medical bureaucracy to another—with the best care often falling through the system’s cracks.
But, so far, Grissom is skeptical of how well the new program can serve her needs.
“I wasn’t happy at all because with us, people in our situation being disabled or people needing care from caregivers, the continuity of our care is very important,” she said.
Almost a Half-Million People
Grissom is among the almost half-million low-income elders and people with disabilities being initially enrolled in the state’s new program, and many have been confused by CMC’s complexities, leaving them uncertain of whether they will be able to remain with their current doctors and other health care providers. If successful, the state would expand the program to 1.1 million people in all 58 counties.
A healthcare advocate and volunteer with Personal Assistance Services Council (PASC), Grissom stressed, for instance, that the transition to CMC has been a swift change that has a blanketing impact on many African-Americans, who are often struggling to manage their own healthcare needs.
Dr. Bradley Gilbert shared similar views, saying, “It is critical to keep all newly CMC-enrolled members fully informed throughout the transition process because it impacts how they get care.” But Gilbert, chief executive officer of Inland Empire Health Plan (IEHP), emphasized that in the existing system, people “get fragmented care with many different healthcare providers.”
California created CMC to provide coordinated care for people dually eligible for the federal Medicare and the state’s Medi-Cal program, serving lower-income individuals. Gilbert explained in a statement that because most CMC-eligible beneficiaries have chronic illness, the new program aims to help smooth their access to needed care.
CMC, one of about 20 coordinated-care programs states are rolling out as pilot programs under the Affordable Care Act, is being tested in eight California counties over three years. Eventually, the state plans to extend CMC to 1.1 million “dual eligibles” in all 58 counties.
Only certain health insurers are approved to participate in the program in each county. The approximately 50,000 Cal MediConnect beneficiaries in Riverside and San Bernardino counties can choose either IEHP or Molina Healthcare.
Key new benefits they must offer include a care coordinator assigned to work with each person to ensure their access to services in both Medicare and Medi-Cal, especially such long-term services and supports as in-home care, adult day health centers, care management and nursing facility care when needed.
In addition, CMC patients will receive a new vision care benefit and have non-emergency transportation covered, such as a taxi to a doctor’s appointment, when an ambulance would not be needed.
But CMC is partly an optional program, and beneficiaries have the right to decline the program or opt out at any time even after giving it a try. Those who ignore notices from the state that they must make a decision will be automatically enrolled in one of the approved CMC health plans. However, in then, they can chose to leave the program at any time—as long as they also sign up for one of the managed care plans that Medi-Cal now requires.
The state health department is sending those eligible for CMC a series of three blue envelopes with announcements about the new program starting 90 days before the month of each person’s birth. The material explains the decisions people must make, weighing such concerns as whether or not the participating insurance plans in their county include their physicians.
When Your Doctor’s Not in Plan
In cases when someone’s doctor is not in the plan, the state allows insurers like Molina and IEHP to permit that doctor to continue treating the individual, but only for a limited six or 12 months, depending on the situation.
This temporary arrangement allows the dual-eligible person to try CMC out. By the end of this trial period, the doctor may agree to sign on to the health plan; the patient may decide to remain in CMC and find a new physician; or the beneficiary can opt out of CMC and stay with the doctor, as long as he or she enrolls in a Medi-Cal managed care plan.
Plans like IEHP and Molina are sending enrollment “kits” to their potential CMC members with their list of benefits and information about their participating doctors, pharmacies and the prescription drugs they cover on their “formulary” lists of medications.
Since CMC began in San Bernardino and Riverside Counties last April, African-American participation has been limited. For instance, as of Nov. 1, approximately 1,000 of IEHP’s CMC members are African-American, about 11 percent of its total CMC membership.
Asked about how information is created and distributed to ethnic groups, IEHP’s Bradley said, “CMC is a highly regulated program.”
Partly because of past marketing abuses by insurers, state and federal authorities set strict policies for the new CMC program on what information a plan can send to beneficiaries. For example, they require that plans use some written material as is, limit what a plan can modify in describing its specific program, and requires that member materials be written at sixth-grade reading level so everyone can understand what the plan involves.
Public Education “Not Seamless”
Despite these precautions, Grissom said that even as a healthcare advocate and educator, she found the influx of information about CMC to be a lot to dissect. That means it may be more difficult for the average person to fully comprehend, she said.
Grissom added that since becoming more involved in the CMC education and outreach effort through PASC, her initial negative feelings about the program have remained “completely the same.”
She continued, “The education we’re getting is not seamless. It seems like they’re rolling it out, and we have until January to get everything done . . . . If you don’t have your ducks in a row, that’s not going to be a good thing.”
Because such choices are complex, Grissom emphasized how important it is to ensure that dual-eligible beneficiaries are able to understand precisely what areas of coverage will impact their lives and how to anticipate any changes to their co-pays or continuity of care.
The state has developed both online information (www.calduals.org) and free telephone or in-person assistance in each Cal MediConnect county—in any language—to guide beneficiaries in making the choice. In San Bernardino and Riverside Counties, people can call the Riverside County Health Insurance Counseling and Advocacy Program (HICAP) at 800-434-0222 or 909-256-8369.
Corey Arvin wrote this article for Black Voice News with support from a New America Media fellowship, sponsored by The SCAN Foundation.
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