If you’ve received a Medi-Cal managed care plan denial for a medical treatment or prescription drug your doctor believes you need, it can be discouraging, to say the least. It’s important to remember, however, that you do have options following such a denial. Even more importantly, there is potential help out there in the form of the Law Offices of Scott Glovsky. Attorney Scott Glovsky has been helping people in certain situations for many, many years. This is what he and his highly skilled staff do, day in and day out. Don’t give up if you’ve received a Medi-Cal managed care plan denial.
What are Medi-Cal Managed Care Plans in California?
Medi-Cal is health care for those with low or no income. In fact, Medi-Cal is the name for Medicaid in the state of California. Some of those who have Medi-Cal are in a Medi-Cal Managed Care Plan, which is supposed to provide cost-effective health care via managed care “delivery systems.” Medi-Cal Managed Care contracts with a network of providers with an emphasis on primary and preventative care. (Note that the predominant form of Medi-Cal Managed Care Plans is Managed Care Organizations, or MCOs.)
All basic benefits covered by most health care plans are covered under Medi-Cal Managed Care, including prescription drugs, and even sometimes vision and hearing care. Medi-Cal dictates that you have one doctor or clinic for the majority of your healthcare needs, although you can change doctors or clinics after being assigned one when you join the plan. Your income and your medical issues are both considered when determining whether you qualify for Medi-Cal Managed Care.
How Do Medi-Cal Managed Care Plans Work?
Medi-Cal is the largest state Medicaid program in the nation, insuring almost one-third of all California residents. Under the Affordable Care Act, California expanded Medi-Cal eligibility, significantly increasing the number of Medi-Cal beneficiaries, and as of July 2021, 82 percent of Medi-Cal beneficiaries were enrolled in Medi-Cal Managed Care Plans. Different managed care models operate in different California counties, shaped primarily by the available mental health services, public hospital services, and specific long-term services.
Managed Care Plans have contracts with healthcare providers and medical facilities that provide care for their members at reduced costs; these providers make up the “network,” and how much of your specific care the plan pays for depends on the rules of your network. Because managed care plans emphasize primary care and cost containment, those with chronic diseases, disabilities, or mental health issues may not receive adequate access to specialists who are qualified to diagnose and treat their specific conditions.
Did CMS Change Medi-Cal (Medicaid) Managed Care Rules in 2024?
CMS published the “Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F) on April 22, 2024. This rule aims to strengthen managed care programs to better serve the needs of recipients by enhancing access to, and the quality of, care. Specifically, this rule improves standards for timely access to care and state enforcement actions. It also creates a quality rating system for managed care plans and establishes maximum wait times for outpatient mental health appointments at ten business days and for primary care appointments at fifteen business days. Each state must disclose dollar amounts paid to providers. And there are several other changes.
What California Insurers Offer Medi-Cal Managed Care Plans?
At the beginning of 2024, twenty-two health insurers were offering Medi-Cal Managed Care Plans in California. To find plans in your county, you can look at this document that specifies plans in each of the state’s 58 counties. Some of the California insurers that offer Medi-Cal Managed Care Plans include:
- Aetna CVS Health
- Blue Shield of California Promise Health Plan offers Medi-Cal Managed Care in Los Angeles and San Diego Counties.
- Health Net offers low or no-cost medical and dental benefits to qualified Medi-Cal members in Los Angeles and Sacramento counties.
- IEHP (Inland Empire Health Plan) was established in 1994 in the state as a Medi-Cal Managed Care Plan in the Inland Empire region. Today, IEHP offers Medi-Cal to residents in Riverside and San Bernardino Counties.
- Kaiser Permanente participates in Medi-Cal in many California counties, so those who are current Kaiser members who have had a change in their financial situation may be able to continue with Kaiser if they qualify for Medi-Cal and are in a participating county.
- L.A. Care is a health plan for Medi-Cal members in Los Angeles County.
- Molina Healthcare of California reached an agreement to deliver Medi-Cal services to Medi-Cal Managed Care members in 21 counties in the state, beginning January 1, 2024.
- VHP (Valley Health Plan) includes Medi-Cal Managed Care for those in certain counties.
Why Would a Health Care Provider Deny Care?
As a Californian with a Medi-Cal Managed Care Plan, often your medical care is decided by your assigned physician and is not approved or denied by your health insurance company. If you receive a Medi-Cal Managed Care Plan denial from your IPA, it can be devastating. (An IPA is an Independent Practice Association, Independent Provider Association, or Independent Physician Association, which are all networks of doctors with their own practices.) Physicians may join IPAs to reduce their overhead, sharing billing, office systems, office space, electronic health records, and reimbursement processes.
To understand why a Medi-Cal Managed Care IPA might deny care, you must first understand capitation payments. Capitation payments are fixed monthly payment amounts the IPA receives from each assigned member, regardless of that member’s need for medical care. A member who receives little or no medical care equals pure profit, while a member who requires significant levels of medical care could cost the IPA more than the capitation amount received.
Risk-sharing pools are another reason an IPA might deny care. Risk-sharing also involves transferring the cost of healthcare services from the insurer to the IPA and medical providers. The insurer may hold back a percentage of the capitation payments at the beginning of the year, reserving those funds for things like hospital stays. The payments are placed in a “risk-sharing pool,” and at the end of the year, if the amount for hospital stays is more than the amount in the risk-sharing pool, the additional costs may be borne by the IPA.
If the amount is less than what was placed in the risk-sharing pool, the IPA may receive a percentage of the remaining funds. The bottom line is that less healthcare equals bigger IPA profits. Risk-sharing pools and capitation payments provide financial incentives for IPAs to deny healthcare to their members as a means of increasing their own profits. This means if your IPA considers you a “risk,” in that you may cost them more than they receive, they may issue Medi-Cal Managed Care Plan Denials.
What Should You Do if You Have a Medi-Cal Managed Care Plan and Your Claim is Denied?
If you have a Medi-Cal Managed Care Plan and your claim for a medical treatment has been denied, you may feel as though you have little recourse. This is far from the truth. When you receive a Medi-Cal Managed Care Plan denial, you are entitled to an appeal. An appeal is used when your care plan has taken an action that “affects your care, such as delay, modification, denial, or reduction of services, denial or only partial payment for a service, or the determination that the requested service was not a covered benefit,” (known as an Adverse Benefit Determination).
The appeal process is a little different between a straight Medi-Cal denial and a Medi-Cal Managed Care Plan Denial. For a Medi-Cal Managed Care Plan Denial, you will often first contact your plan’s customer service number. If your denial is not reversed, you can often file an appeal with your care plan. An appeal is a review by your managed care plan and generally must be filed within 60 days from the date you received your notice of Adverse Benefit Determination.
How the Law Offices of Scott Glovsky Can Help with Medi-Cal Managed Care Plan Denials in California
If you are on a Medi-Cal Managed Care Plan and have received a denial for service or Adverse Benefit Determination, it can be daunting to navigate your way through the appeals process. You may not have to do this on your own. Our firm helps individuals with Medi-Cal Managed Care Plans that also have a private insurance company involved. The good news is that you don’t need an army of lawyers to fight a big insurance company. You only need one person who is highly experienced, knowledgeable, and skilled—and who cares enough about you and about justice—to go to battle on your behalf.
The victories of the Law Offices of Scott Glovsky have positively impacted millions of California policyholders by forcing insurers to treat members with respect. Attorney Scott Glovsky and his staff are relentless when fighting for the rights of their clients. As we tell prospective clients—If results matter, hire us. Contact the Law Offices of Scott Glovsky today for assistance with your Medi-Cal Managed Care Plan denial.