Many Californians with Covered California or Medi-Cal health coverage hover near the intersection where the two programs meet. When their incomes fluctuate, however, that “hover” can turn into a “bounce.”
State officials say the transition between Covered California and Medi-Cal is supposed to be “seamless.” But in reality, moving from one to the other sometimes puts Californians’ health coverage — and their health — at risk.
“There’s not a seamless transition. There’s not someone helping them figure out who to call or how to navigate the system,” says Jen Flory, senior attorney at the Western Center on Law and Poverty. “Frankly, it’s not working correctly.”
Question: I work for a temp agency and keep falling off Medi-Cal because my income changes. But I need to see a doctor for my cancer. What should I do?
Answer: Jesse Weiss, 52, lives in Yreka, near the Oregon border where specialized medical care can be hard to come by, no matter what kind of insurance you have.
Weiss suffers from several ailments, but the most serious is the skin cancer that has remained essentially untreated since it was diagnosed three years ago and “has completely destroyed the top of my head,” he says.
Weiss falls into and out of Medi-Cal, which is the state-federal insurance program for low-income residents. When his income is too high for Medi-Cal, he should be able to get coverage through Covered California, the state health insurance exchange.
But Weiss says he finds the bounce confusing, and isn’t sure he could afford a Covered California plan even with its promised subsidies.
When Weiss has Medi-Cal, his local doctor refers him to a specialist at University of California at Davis Medical Center, about four hours away. But it’s a months-long wait, and he never gets in before he falls off Medi-Cal again, he says.
“When I lose Medi-Cal, then I get bumped off this list and have to start all over again,” he says. “It’s like musical chairs. If you lose your spot, you’re gone.”
Weiss is one of about 12 million Californians in Medi-Cal, while about 1.4 million people have Covered California plans.
With some exceptions, you qualify for Medi-Cal if you make up to 138% of the federal poverty level (FPL), or about $16,200 for an individual.
Between 138% and 400% of FPL, you qualify for subsidized health insurance from Covered California.
With 138% as the dividing line, movement between the programs is common.
The UC Berkeley Center for Labor Research and Education estimates that 16.5% of Medi-Cal enrollees will become eligible for Covered California during the course of a year because of income increases.
On the other hand, about one in five people with subsidized Covered California plans will drop into Medi-Cal or other public coverage, the center estimates.
If you have a Covered California plan, you may be bumped into Medi-Cal when the agency attempts to verify your eligibility, says spokesman Dana Howard.
This could happen midyear, when Covered California checks sources such as federal tax records to determine whether your income matches the estimate you gave when you enrolled. Last year, about 85,000 people were determined eligible for Medi-Cal during this process, he says.
If you’re in Medi-Cal, you may fall off during the annual renewal process if you’re no longer eligible or don’t return your renewal materials, says René Mollow, deputy director of health care benefits and eligibility for the state Department of Health Care Services.
If you’re in either program, you’re supposed to report changes in income or family. If you do and your eligibility changes, you may be moved.
Unfortunately, people are also falling off for incorrect and sometimes inexplicable reasons, health consumer advocates say.
For instance, the Covered California and Medi-Cal computer systems “aren’t talking to each other very well. The county will say one thing and Covered California will say another thing,” says Cori Racela, associate director of policy and litigation for Neighborhood Legal Services of Los Angeles County. “It’s the consumer who falls between the cracks.”
Many consumers don’t find out they’ve been incorrectly switched until afterward, says Sonal Ambegaokar, senior attorney at the National Health Law Program.
“There’s often a gap in coverage before they can get reenrolled,” she says. “During that time, they have medical needs that are not being addressed.”
Mollow says Medi-Cal has to give members at least 10-days notice before they’re disenrolled. If you don’t receive adequate notice or disagree with the decision, you have appeal rights, she says.
Read the notice you receive in the mail carefully because it provides directions for appeals.
That’s not your only option if you think there’s been a mistake or need help.
Start with your county human services agency or Covered California (800-300-1506).
Request a Medi-Cal or Covered California eligibility hearing by calling (855) 795-0634 if you disagree with a change in your benefits.
If you’re going to report a change that affects your eligibility, whenever possible do it early in the month, Racela suggests. Because you can keep your current coverage through the month, reporting early will provide a cushion in case you encounter challenges when you enroll in the new program.
If you know you’ll be switching programs and are taking prescription medications, consider asking your doctor to prescribe a three-month emergency supply in case there’s a delay in refilling your prescription, Ambegaokar says.
If you’re undergoing treatment when you lose eligibility in a program, you have “continuity of care” rights, Mollow says. Once you’ve been switched, contact your new health plan immediately to explain your situation. In some cases, you may be able to keep your doctor while your treatment proceeds.