Medi-Cal Regulators Accused of Lax HMO Oversight : Health care: Suit will be filed alleging the poor are being hindered from disenrolling from health plans in timely fashion.

TIMES STAFF WRITER

Patricia Coronado says state regulators failed to protect her when she tried to disenroll from a private managed-care health plan for Medi-Cal recipients and got a big runaround from the company.

The Whittier woman's problems began in June, when several packages arrived in the mail from Universal Care, a Signal Hill health care firm. The packets included insurance cards and brochures that said Coronado had enrolled her family in Universal's program for recipients of Medi-Cal, the medical program for low-income Californians.

Coronado claims that unscrupulous door-to-door salespeople tricked her into joining Universal's plan and that the company ignored her repeated attempts to disenroll until a Legal Aid lawyer intervened.

A Universal Care representative said the company's owner was out of town and unavailable for comment.

Consumer advocates report a growing number of complaints similar to Coronado's as the Wilson Administration proceeds with plans to move more than 2 million Medi-Cal recipients into managed-care over the next few years. Nearly 1 million Medi-Cal members are in such plans currently. Proponents of the move to managed care say the effort will mean improved access to health care for the poor and lower costs eventually, but consumer advocates say the transition is proving rocky.

In a civil complaint to be filed today on behalf of all Medi-Cal recipients, Legal Aid and consumer organizations accuse the state Department of Health Services of lax oversight of the Medi-Cal program. The suit, to be filed in Los Angeles County Superior Court, does not name Universal Care or any other private Medi-Cal contractor as defendants.

The suit will claim that state regulators are failing to ensure that Medi-Cal recipients who are enrolled in managed-care plans are able to disenroll on a timely basis. Federal law permits Medi-Cal recipients to disenroll from the plans without stating a reason, and requires disenrollment within 45 days after a request.

The lawsuit will claim that some managed-care plans are "illegally delaying or denying enrollee disenrollment requests" in order to generate larger profits. The suit will allege that some plans routinely fail to respond to members' oral and written requests for disenrollment forms, that they place telephone callers on "never-ending hold" when they ask to disenroll, and that they routinely misplace disenrollment forms or fail to send them to state authorities.

Consumer advocates contend that the disenrollment problem is exacerbated by unscrupulous marketing practices of some private Medi-Cal health plans.

"A lot of the people we are seeing are signed up as a result of misleading or outright fraudulent marketing," said Lourdes A. Rivera, an attorney for the National Health Law Program in Los Angeles. Co-petitioners in the suit include Consumers Union and the Latino Issues Forum in San Francisco, Legal Aid Foundation offices in San Francisco and Los Angeles, and Centro la Familia in Fresno.

The Department of Health Services, which oversees the Medi-Cal managed-care program, "has been less than responsive to these problems," Rivera said. "They need to respond to the disenrollment problem in a systematic manner."

State officials say they recognize the problems and have plans to address them.

Joe Kelly, chief of the Medi-Cal managed-care program for the department, said the state plans to eventually hire third-party companies to handle member enrollment. The move "will take disenrollment out of the hands of the health plans," he said.

Such a change might have helped Coronado, a mother of four who claims her pregnant daughter Venina's medical care was jeopardized by Universal Health's delays. The daughter, who had a problem pregnancy, postponed seeing a doctor because of the confusion over medical coverage.

Coronado said she tried for three weeks to get a disenrollment form. She first asked the company to mail her a form but that one never arrived. Frustrated, she went in person to Universal's offices, where she said she was told that the managers who handled disenrollment had gone for the day and that the forms were "locked in a drawer."

"If I hadn't gone to Legal Aid, I would still be on this plan," Coronado said.

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