April 5, 2016
Source: Los Angeles Daily News
By Emily Bazar, California Healthline
It wasn’t until a doctor ordered medical tests for Adriana Vitale that she discovered her Covered California coverage had disappeared.
“I was shocked. I was crying. I was depressed,” said Vitale, 61, of Downey.
Her insurance had been dropped, even though she had paid all her premiums on time.
She’s not the only one. A number of people who have signed up for Covered California coverage have been dumped from their plans unexpectedly, without explanation — even though their premium payments were up to date.
Others were shifted into Medi-Cal without approval or consent. They found out after the fact.
It’s been a persistent, but apparently unquantified problem, since 2014.
In Vitale’s case, she went to the hospital in December for a bleeding ulcer. Her daughter called the insurance carrier, Blue Shield, to confirm that her mother’s follow-up tests would be covered.
“They said, ‘We don’t have anyone by your mom’s name covered by Blue Shield. But we have all these medical bills in her name,’ ” the daughter, Kathy Castilla, recalled.
It took an administrative law judge in late December to resolve the problem. He ordered Vitale’s policy reinstated.
He noted that neither Blue Shield nor Covered California could explain why Vitale’s policy had been terminated without her request.
“The failure to be able to explain these discrepancies casts doubt on Blue Shield and/or (Covered California) record keeping as it applies to appellant’s coverage,” he wrote.
Several other customers whose paid-up policies disappeared talked to California Healthline about their plight, as did health care advocates who help them unravel the bureaucratic knots.
The evidence is anecdotal. Not even Covered California knows how many people might be affected.
“We are not aware of anything that would result in the terminations of a large number of consumers without notification, or of any problems with our process of notifying consumers who are deemed eligible for Medi-Cal,” spokesman Larry Hicks said.
When pressed further on whether Covered California is aware of the termination problem and, if so, how many people it affects, Hicks issued this statement: “While we want every enrollment and transition to be as smooth as possible, we know that with 1.5 million consumers, there will be times when issues come up that need to be resolved. We deal with these on a case-by-case basis as we discover them and, where appropriate, look for ways to improve our existing processes.”
No one seems to know what’s causing these terminations. Nor is it clear whether they’re a result of errors committed by Covered California or the health insurance plans — or both.
Blue Shield declined to comment on Vitale’s case, citing privacy concerns, but said there are several reasons why someone’s plan might be terminated. These include nonpayment of premiums, not providing proof of citizenship and changes in income that would make the person ineligible for a subsidized Covered California plan, the insurer said.
None of those seem to apply to Vitale.
“Blue Shield is committed to providing coverage to all Californians — this includes working closely with Covered California to decrease the state’s uninsured rate,” said spokesman Clinton McGue.
Covered California’s Hicks suggested that consumers who face problems with their coverage and are unable to resolve it with their insurer contact the exchange’s customer service center at 800-300-1506.
Vitale’s daughter said she tried that. The service center acknowledged an “error,” but when she asked whose it was, “they didn’t want to tell me,” she said. The agent did tell her the problem would “take a while to fix.”
The family turned to Neighborhood Legal Services of Los Angeles County, which helped them take the case to the administrative law judge.
But Vitale still hasn’t had her medical tests, in part because it has taken so long to get her coverage reinstated, despite the judge’s order.
“I wish they would never do this again to another person,” she said. “It’s a terrible thing.”
Wendy Heath of San Diego also contacted Covered California’s help line after her policy was dropped. She said she had renewed her Health Net policy through the exchange and paid her January premium. When her February invoice didn’t show, she called Health Net.
“They said, ‘You don’t need to pay us. As a matter of fact, we’ve refunded the amount you paid for January,’” Heath, 39, recalled. “They said, ‘Your plan was canceled by Covered California.’ ”
When she called Covered California, she said, a representative could only acknowledge that “we’ve seen the issue” with her case. Eventually, she got her coverage restored with the help of a community service group, San Diegans for Healthcare Coverage.
In the meantime, she had canceled two physical therapy appointments, afraid she might not be covered, she said.
Health Net spokesman Brad Kieffer said policyholders having trouble with their coverage should call the plan at 888-926-4988.
“This is not the experience we want for our members,” he said. “Anybody who feels that this has happened to them can call us and we’ll look into it and resolve the matter on their behalf.”
Jan Spencley, executive director of the San Diego group, said there has been an uptick in terminations since the beginning of the year. When Spencley steps in to help consumers resolve these cases, she finds they usually did everything right, she said.
She’s said she’s received no clear answers on what’s wrong, but believes that some problems may stem from flaws in Covered California’s computer system and its communications with health plans.
“What you end up with are glitches that take ridiculous amounts of time to solve,” she said.
Anjel Jiron, an insurance agent based in La Mesa, said a handful of her clients have been unexpectedly terminated from their Covered California plans in the past six months. While these terminations have been going on all along, “it has gotten worse,” she said.
Once the problem is discovered, often by accident, it can take months to fix — if at all, she said.
“Whether it’s a person updating their information in their Covered California account or an issue with the insurer and their billing, any simple thing throws off the entire process,” she said. “Now people are being terminated without any type of notification. There are changes to plans with no accountability.”
In some cases, problem-solving means going back and forth between Covered California and the insurer.
When a private insurance policy is dropped by Covered California and the consumer is put into the state’s Medi-Cal system without notice, there’s a third bureaucracy involved: counties.
Rachel Freed, 43, of Sonoma got a Covered California plan through Kaiser Permanente on Jan. 1. She said her two children were eligible for Medi-Cal but that she’s in an income category that qualifies her for Covered California.
(Income requirements for Medi-Cal are different for adults and kids.)
One day last month, Freed received an email from Kaiser saying her Covered California plan had been canceled, effective immediately.
“I freaked out. Then I called Kaiser. They said, ‘Oh yeah, it looks like you requested that your plan be terminated,’” she recalled. “I said, ‘Oh my God, that’s crazy.’”
She next called a Covered California customer service rep who also told her that she had terminated her plan. “I said, ‘That’s not true’.”
A few days later, she received a letter from Covered California telling her she would be enrolled in Medi-Cal.
As best as she can figure, her meeting with a county worker in January about her children’s Medi-Cal coverage somehow triggered her move to Medi-Cal, even though she believes her income for this year was high enough to make her eligible for Covered California.
“I’m stuck in Medi-Cal and I’m not sure how to get out,” she said.
After countless hours on the phone, she now feels “powerless.”
“The system is just throwing you around without any consideration,” she said.
Covered California spokesman Hicks said sometimes the exchange receives income information from counties — not consumers — that may lead to changes in eligibility. But he said consumers are supposed to be notified.
Consumers should receive three notices — two from Covered California and one from their county — informing them of the change ahead of time, he said.
“If they haven’t received them, one possible reason is that they either gave us an incorrect mailing address or they moved and didn’t tell us,” Hicks said.
Freed says she’s lived at her current address for eight months and the address she gave was correct.
She has a pile of letters from Covered California to prove it.