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Apparent Random Termination of Medi-Cal Coverage?

By on | 24 Comments

Question: My Medi-cal was terminated 5.28.14 with no explanation or warning. My pharmacist informed me. After several phone calls, everyone agrees I should have no been terminated but they have no advice (CA Calif. and Medi-cal reps). No one would escalate my call. I reapplied to CA Covered and they will recommend Medi-cal. Meanwhile I am without coverage of any kind. Is the re-instated insurance retroactive is there some protection from termination that was not my fault. The law 14005.37 states that I should have been notified and received a chance to advocate for myself. I have heard nothing. What recourse do I have. Aren't they effectively ignoring the law?


Answer: You'll have to file for a hearing. You have 90 days from the date of the termination letter to request a state hearing. The form for that is on the back side of the termination notice or you can do it by phone. When you file you will receive "aid paid pending" meaning that your benefits will be reinstated pending the outcome of a hearing. When your Medi-Cal coverage is reinstated, coverage will be retroactive to the cancellation date. In the end, you shouldn't be out anything but the massive headache of getting your case back on the tracks.

24 Comments

I need consultation regarding this issue that just came up yesterday: I’ve been receiving EBT and SSI, but 2 things happened yesterday that will probably terminate my EBT status:

(1) I opened an envelope dated Aug. 31 and discovered inside was a Status of Eligibility form that I had not filled out and sent back, saying that it should be mailed Sept. 5. It also stated that failure to mail it will result in termination of my benefits, which include L.A. Care/Medi-Cal. (2) A couple hours before opening that mail, I opened another envelope which contained a check from the U.S. Treasury with a refund of $2800 (I’d filed a complaint against the unfair garnishment of my Social Security benefits every month for the past 3 years and this was an unexpected refund). So I rushed out to the bank and deposited it (I had $34 left in my account and no employment). THEN I discovered the notice re Eligibility. Mail has often been delivered late in my building and I have an email between myself and the post office manager in my neighborhood that I wrote last month proving it. Years ago, when I failed to file the Eligibility form, I was threatened with a “Fraud” lawsuit by the government. I met with their lawyer and had to provide paperwork showing that I received the notice late, etc. My questions for you are:

(1) Should I respond late to the notice with attachment from the post office explaining why it’s late?

(2) I called the welfare office last night and got an automated reply to my question about my status and it said: “Will terminate October 30.” So should I just let this go and wait to be officially terminated, and try to take care of my finances on my own (this seems like the more likely scenario and doable right now)?

(3) Because I have been living on the edge financially, I owe money, have a car in need of registration that is 2 years overdue and insurance, etc., it is possible that I could burn through the windfall/refund within a couple months, and yes, I plan to look for work at age 65 to avoid this.

But my major concern (and reason for contacting you) is:

(4) I had cataract surgery over a month ago on my right eye and the operation for the left eye is slated for Oct. 11. So my main worry is losing health benefits (Medi-Cal/Medicaid). Realistically, what can I do to protect my insurance situation? Should I just not contact the welfare office and hope that my benefits terminate after surgery in October? And if they do terminate earlier, do you happen to know what happens next to my health care benefits, or should I just start contacting my provider and find out to prepare myself?

I apologize for the length of this explanation/questions. I’m a Los Angeles resident, FYI. Thank you for any light you can shed on this!

Max… any word from your inquires on illegal Medi-Cal disenrollments?

I have have had a BUNCH of clients dis-enrolled from their Covered California health plan, often just days before Medi-Cal became active, and without notice until after the fact.

I am then contacted to fix these enroll and dis-enrollment concerns; therefore member and broker are forced to ‘fix’

My latest, is from a client, enrolled in a private insurance carrier health plan as provided through Covered California, who was never enrolled in Medi-Cal through Covered California or the Cal-HEERS system since January 2014. In fact, he has never been eligible for Medi-Cal from January 2014 to present. This client was covered by Medi-Cal in 2013 or prior, and recently (in mid 2015) the State came in, changed his Cal-HEERS/Covered California application to income which is years old and currently irrelevant, and locked his account under automatic audit (called a soft pause), and forced him off his private carrier health plan, and additionally forced him on to Medi-Cal… when he is NOT in fact eligible for Medi-Cal. This dis-enrollment was made just days prior to the Medi-Cal effective start date, of course written notice of this health plan disenrollment and Medi-Cal enrollment only received well after the Medi-Cal effective date.

No word from Peter Lee on this general concern ever.

Issue ongoing over a year now.

Clients relay this says volumes about the CovCal organization’s care for its members.

I now have at least three clients whose CoveredCA applications were unlawfully altered by anonymous employees of the local Medi-Cal agencies in Los Angeles and San Mateo counties, which resulted in either their termination from Medi-Cal or health insurance, with no ability to reinstate through CoveredCA. This is a violation of Section 10382 of the Insurance Code which states: “No alteration of any written application for any disability policy shall be made by any person other than the applicant without his written consent * * * . The making of any other alteration without the consent of the applicant is a misdemeanor.”

When I wrote to Kirk Whelan of CoveredCA about this, he replied: “the code references a disability policy and not a health insurance policy” — which obviously indicates that the folks at CoveredCA don’t know that health insurance is a form of disability insurance, one of the 22 “classes” of insurance defined in the Insurance Code (health insurance is not a “class” of insurance, but a subset of disability insurance, like disability income or long term care insurance).

As WJM indicated, these unlawful changes are being made without the prior knowledge or consent of the affected persons, and without subsequent notice to them after the changes are made. In attempting to correct the most recent incident, which I only discovered when I attempted to make a change to my client’s income following her acceptance of new employment after a period of unemployment, The apparent change was made following a review of her 2014 income tax return which included an entire year of income. But it has no correlation to her 2015 income which was cut off following termination from her employment early this year.

The alteration of my client’s application resulted in the following “eligibility determination”: Not eligible for APTCs, Not eligible for CoveredCA health plan, Not eligible for Medi-Cal. However, with an annual MAGI of about $23,300, my client is eligible for APTCs and a CoveredCA health plan with Cost Sharing Reductions.

When I tried to enlist the help of a SHOP CSR, I was told that once the DPSS makes a change to the application, only DPSS can make further changes. Filing a new application will only result in the same eventual loss of coverage.

In Los Angeles County, it is a near impossibility to contact anyone live by phone, and when given the name of a specific eligibility worker handling a person’s file, that person has “telephone hours” between 8am and 9am, never answers his/her phone, and has no voice mail. When attempting to go to the local DPSS office to see the employee, the visitor is told that they must make an appointment by calling the employee. How convenient.

On July 2, I sent a formal complaint to Minerva Lopez, Chief Investigator at the Los Angeles regional office of the Dept of Insurance Enforcement Branch, Investigation Division, asking CDI to become involved. We’ll see what happens. But my guess is the number of similarly affected persons throughout California is in the hundreds or thousands, if not many more.

WJM, you write incredibly well.
Best of luck in you seeing this through.
Persevere, you will succeed! My suggestion is to request assistance from and contact the Medi-Cal Managed Care Office (MMCD) - Office of the Ombudsman: Medi-Cal Managed Care Office (MMCD) - Office of the Ombudsman: http://www.dhcs.ca.gov/services/medi-cal/Pages/MMCDOfficeoftheOmbudsman.aspx Hours of Operation: Monday through Friday, 8am to 5pm PST; excluding holidays —
— By Phone: 1-888-452-8609 —
And, By email (not confidential): MMCDOmbudsmanOffice@dhcs.ca.gov

Also may be helpful:

California Office of the Patient Advocate

Medi-Cal Complaints options:

http://www.opa.ca.gov/Pages/Medi-CalComplaints.aspx

Hi Craig, I don’t know how much more detailed I can be, do you have any specific questions? If there’s more to it, it’s information I don’t have. I’m just seeking out any other people who may have been in similar situations that may be able to shed some light on what’s going on. I appreciate any help I can get :)

Hello, this be Craig. Yes it’s true. Google it up, “wrongful termination of medi-cal”. It happened to me and it cost me. I was hit by a car on my bicycle and subsequently suffered from a broken bone in my foot, dxm near a compound fracture threw the bottom of the said foot. It took them once recertification paperwork was done in there office , months it took just for them and there system to reinstate. Then month’s for SSA to follow up on there paperwork. To make a long story short, um, 8 months before I received my back money they took out of my check. In the meantime I had to volunteer at 4food banks just to eat because my check was short , I could pay rent but no money to buy food or do the laundry or even fix the damages to the bicycle. I ran up bill’s that did get paid including a ticket. My cards were not good at all, A, B and D. I could not even get the cop that wrote the ticket to call an ambulance or take a statement of hit and run. I was bleeding from my hand. So trust me, I do have cards that are good now and all bills paid for that I barrowed. Over 2 million people were terminated wrongly. Recerts I sent, they say never received. I even sent the copy. Get this, get a signed and dated copy at there office of your Recerts filed in person and follow-up on the matters of it. In addition stick to the income levels as in do not earn money that will mess up your check. If you find my statement on the net , Ben Herr i think is the guy i blogged with , well he in chat mode told me what to do but all in all i think there’s more to your case then you care to express or are un able. Google it up like i said however its months not years. I hope this helped you and good luck with your case load in the matters of it.

I’m a single mother of 1 living in Shasta County, I just found out yesterday when I went to pick up my prescriptions that I had been dropped from Medi-Cal from the pharmacist. Calls to the state level told me they couldn’t give me any information and advised me to call the county office, which was closed early for the holiday weekend. I’m waiting for Monday so I can go to my local Health and Human Services office and hopefully find out what is going on.

I had a recertification for CalFresh in May, a month I covered many extra shifts at work for those on vacation, and my income was inflated higher than normal. I was told I still qualified for CalFresh and that I would have to wait for them to send me a letter letting me know if there would be any changes. I received a letter saying my benefits dropped from $364 to $16.. ouch.

I never received any other letters after that. No letters telling me I needed to recertify with Medi-Cal, no letters my Medi-cal was being terminated. I’m a mess, I’m supposed to have an appointment with my MD for a lung infection on Monday and a post-op follow-up appointment with my spinal surgeon. I’m going to be completely out of medications within the next few days and out-of-pocket cost is nearly $500. Obviously, I can’t afford to go to the in office visits either.

I was on transitional Medi-Cal and CalFresh, I had them originally since I became pregnant in December of 2012 and I went on Cash Aid in November 2014 to get assistance for Child Care so I could get a job, and have been employed and reporting my pay through the next two months to maintain my Medi-Cal qualification. I was told about going to transitional Medi-Cal and Cal-fresh, and that I would be restored to regular Medi-Cal and Cal-fresh unless I had a major financial windfall, which I obviously did not. I had received notice in February or March that my daughter would continue to be covered under Medi-Cal, but I may not be. I applied for Covered California so I could be prepared, and was told I didn’t qualify for it, because I qualified for Medi-Cal. I never received any other notices, and was completely caught off guard when the pharmacist told me my Medi-Cal appeared to have been terminated.

I feel completely unprepared for going in to the county Monday morning, and after reading the above comments it appears that it’s not an unheard of situation. I thought maybe it had something to do with the information I submitted for CalFresh, but I really don’t know if one hand talks to the other in that case. Any information or advice would be greatly appreciated, thank you.

Craig …

I should have added …

If you are currently receiving Social Security Retirement benefits, then the Part B premium will be deducted from that amount. The SSI increase offsets the reduction in the net retirement benefit.

Craig …

Nothing is really happening to your Medicare or Medi-Cal or SSI — other than money is being shifted from the right pocket to the left. Except that it’s taking two months for that to happen, and your empty pockets will have to pay for Medicare Part B during those two months.

Instead of the State of California paying the $104.90 Part B premium to the Social Security Administration/Medicare for you, they will begin paying that to you directly, and you, in turn, will need to pay that to Social Security/Medicare. In fact, the State is increasing your SSI payment by a few dollars more than the $104.90.

The only real problem is the time lag between the changes. You needed to pay the Medicare Part B premium in March and need to pay again in April with the limited funds you have. Beginning in May, you will have the added funds you need to pay those premiums.

Effectively, the State of California cut you off without advance notice and without adjusting your SSI payment for the change. Multiply $104.90 by the thousands of other individuals who are in the same boat, and you can see that the State is the big winner in this change.

Unless you are receiving a benefit check directly from Social Security, from which the Part B premium may be deducted, you must arrange to make monthly payments of the Part B premium on your own. If you have a bank or credit union checking or savings account, you can probably set up a “recurring payment” to Social Security/Medicare each month via paper check or automatic debit (ACH) at no cost.

Be aware, however, that future Part B monthly premiums are likely to increase, and those changes, if any, will occur on January 1 of each year, after being announced in the preceding September or October. It will be your responsibility to keep up with the premium changes until you turn age 65 and begin receiving a retirement benefit from Social Security instead of a disability benefit.

Good morning. This be Craig Miller. Hears the follow up. recived letter from SSI. I need a lawyer just to keep up with the act. letter contents:

We are writing to you about your benefits.

What you should know.

The State of California will no longer pay your Medicare part B ( medical insurance ) premiums after February 2015. You must pay premiums starting March 2015.

What we will pay and when.

you will receive $806.20 for April around May 1, 2015.

After that you will receive $1016.00 on or about the third of each month.

it continues on. comment: I had , until this fiasco free medi medi , A , B. I need to have my part B paid by the state of California like I had it going. Why should I be forced to pay after already getting A, B, Medicare A and B. Something is wrong hear. Please help.

Thanks again for your attention in the matters of it.

MEDI-CAL TERMINATED - NO LETTER - WHAT NEXT?

My Medi-Cal coverage was dropped, even though I filled in the re-certification letter and sent it in. I received nothing in writing from Medi-Cal, and only found out through my Pharmacy a week ago. I have no idea when it was terminated and can only assume it’s due to the fact that the re-certification letter did not get processed.
It seems like every other county but LA was capable of processing letters and assisting there beneficiaries, but LA simply dropped the ball.
After countless failed attempts to contact LA County Social Services by phone, it seems that I have no choice but to go my local office and find out what happened.

My questions are these:

Will my Medi-cal be reinstated or am I expected to start over from scratch? What happens if they deny my application?
Can I still file an appeal? Should I file one now, even though I don’t know the exact date I was terminated?

So very disappointed in the system…again.

Hello Max Herr,

This be Craig Miller.

I thank you for the information you provided, The direction and your attention in the matters of it.

I followed your advice and guidance and yes you did the right thing. I got there and did exactly what you said.

I now have the situation going through the steps of due process. My worker will be getting a call from me in 7 - 10 days as per. I have copies and was given a receipt.

My Medi-cal is in progress of being reinstated.

Thanks again, Craig Miller.

Craig …

LA County is one of the worst offenders in the Eligibility determination process, and, personally, I think the employees at DPSS are simply dragging their feet for the purpose of job security. All of this is supposed to be “rubber stamp” simple.

I can certainly understand them “losing” your paperwork. I have a client who is NOT Medi-Cal eligible at all who keeps getting Benefit ID Cards in the mail for himself and his daughter (who lives in NY), and when I’ve tried to call DPSS on his behalf to try to put an end to this, I’ve discovered that his case has been passed to at least three different case workers, and if I can even get to one, it’s not the current one, and they can’t transfer the call to the right one or they don’t know who the right one is, or BLAH, BLAH, BLAH.

LA County DPSS will not spend the money for a 21st century phone system that includes voice mail, because that would leave a track record of incoming calls that were never answered or responded to.

It will take someone like you and others similarly abused (I have several clients, like the one I wrote about yesterday who did not return his paperwork, and now his case worker has been out sick for over a month, so he can’t get any help at all) to file a class action lawsuit against the County to stop this behavior. I’m sure one of the attorneys I provide expert witness services to would be happy to take the case — or knows another attorney who would.

You haven’t posted an email address, but you can write to me at max.herr@verizon.net to discuss your situation at length in a more confidential manner.

Continued Los Angeles California is the name given. Long Beach is the name given. Thanks Craig Miller.

Continued:

it is California that has caused the matters that confront the state of mind regarding their respective Medi-Cal notice of cancellations of their benefits. Please contact me at my e-mail address on the appropriate thing to do other then some kind of court. thanks again Craig Miller.

Craig …

You don’t mention which County is involved. That’s where the issue needs to be resolved. The ever-present problem is actually getting to the Eligibility Worker with your file on her desk. That typically requires as close to an Act of God as I’ve ever encountered.

I have a client whose Eligibility Worker has been “out sick” for over a month, and nothing has happened during that entire time. It’s not a legitimate excuse by any means, but I haven’t figured out how to get around it.

If nothing else, file an appeal with the state Dept of Health Care Services. At least that will get something going at a level above the County Medi-Cal agency which is causing your problem.

I received a Notice of Action a Medi-Cal Termination. The reason is they wrote that I did not mail in a statement of facts.

Yes I did mail the statement in and the copy to.

I have never been late with correspondence nor the rent.

What do I do to get my care and cal medi back and nip in the bud any further questions about me qualified or not?

I know one thing that would help, but doing it by phone would only lead to someone stealing my phone right when I need it. You see I know something is up.

I am disabled on disability insurance benefits, have been for quite sometime 10 + years and told I would have and get SSDI the rest of my life.

Thanks Craig Miller.

Mr. Dunbar …

You need to file an eligibility determination appeal ASAP. You don’t indicate what the effective date of termination was, and you may have missed the 90-day filing statute of limitations.

Medi-Cal is required to provide you with a notice of termination at least 10 days prior to the effective date of a termination.

If you have not passed the 90-day mark, then file the appeal immediately. If you need assistance with this process, I may be able to help. Click on my name to be redirected to my website, then call or use the “Contact Us” form to reach me.

My Medi-cal benefits was terminated i returned my renewal application package overnight delivery (4) days before 11-30-2014 due date. Post Office Rep.Before mailing it told me the time it’s going out 11-26-2014 11:15am and will arrive 11:35am next Morning.Post Office CLerk Checked it will arrived show the address shows in the window 031 South Family 17600A Santa Fe Ave Rancho Dominguez Ca. 90221 Medi-cal envelopes. I called for the my Case Worker for a Month 2 times a day,still don’t know it my benefits is active? Until i had my follow up Exam to here my Blood Results but couldn’t see him because my Medi-cal is Canceled and if want continue with my exam ill need to pay out my pocket. So have to go back the Medi-cal Office again and go through this long process if i want my benefits? NOT FARE MY MEDICATION IS TIME FOR REFILL AND NO MEDI-CAL for the 4th time now a Former Hospital Director for 21 years of service.

Paul, yours in an excellent post with very strong advice! Thank you.

I too have clients randomly dropped from Medi-Cal and left without covered. Covered California then will not provide traditional plan enrollment until the system’s next available effective date (if at all), leaving people without available health insurance coverage. Of course, this is inappropriate and not legal to simply drop someone without notice, or with sufficient time before future or retro termination, or without one’s ability to appeal.

I have discovered that Medi-Cal offices have direct access to the Covered California system and each Covered California application and account of each Medi-Cal enrollee. In having such direct Covered California per-member account access, Medi-Cal itself is terminating Covered California Medi-Cal-provided enrollee applicants. Medi-Cal ‘determines’ non-eligibility for some reason, even though the Covered California application/enrollment system says otherwise, likewise as does every human at Covered California, where such Covered California reps also typically determine the enrollee/applicant as ONLY eligible for Med-Cal, yet then Medi-Cal disenrolls these enrollee members retroactively as if never active or enrolled in Medi-Cal at all. This is initially deceptive to the enrollee, of course, where Covered California conveyed to them upon enrollment that they and/or their family/household members were approved and active with Medi-Cal health insurance. Covered California reps then say they cannot do a darn thing about it, except re-enroll people, if possible.

I think Peter Lee is on top of it though…

ANON!!!

You NEVER cancel existing insurance prior to obtaining replacement coverage.

When you wrote “medical” (three times) did you really mean “Medi-Cal” (three times)?

The details of your post are, at best, extremely vague. If you are paying premiums to Anthem, why does your daughter have coverage through IEHP?

“Children” are eligible for Medi-Cal if the household income is below 266% of the Federal Poverty Level (FPL). When the child(ren) live with the mother, then the mother’s income is the determining factor. When the child(ren) live with the father, then the father’s income is the determining factor.

If a child is covered by (or eligible to be covered by) an employer-sponsored health plan, in most cases they must be enrolled in that plan. When children can be covered under two different employer-sponsored plans, you have to know what each Summary Plan Description says about the need for the other parent to carry insurance on the children.

In California (and most other states), the “birthday rule” applies, and the parent with the earliest birthday on the calendar will provide “primary” coverage for the children if they are covered by two or more plans. A wife’s plan, for example, even if there is no cost, can require the husband to cover the children under his employer’s plan if his is the earlier birthday, even though his plan is more expensive. Failure to cover the children in this manner, if required, can mean they have little or no coverage, even if enrolled under the wife’s plan, because that is the “secondary” plan.

What am I missing here? Please help us by providing a bit more information.

With regard to the Q & A you posted today, June 17th, please inform the person who was, by her question, unceremoniously terminated from Medi-Cal (which is NOT what purports to be, but we can have that communication another time) she has total recourse to get it back, as you stated, retroactive to the date of termination.

BUT, she needs to file for a hearing NOW. She is allowed 90 days from the date of the termination letter to request a state hearing. She can do it by phone and/or by just filling out the back of the termination document which should explain her right to hearing. She needs to do this NOW. If she timely files she can receive “aid paid pending” meaning that her benefits will be reinstated pending the outcome of a hearing.

She can represent herself at hearing but most (90%) find it much too emotionally upsetting to do it themselves. They can have a friend or relative represent them. Or she can be represented by a legal aid advocate or a private advocate who is skilled in this area.

In no event, in my view, if she has a credible situation, should she let her termination just take effect without doing something if she wants her Medi-Cal to continue. The also applies to Cal-Fresh and other programs.

Unfortunately, you do not indicate what county you are in. A termination such as you describe would have occurred at the county level, because once your application leaves Covered Calfornia, it goes to DHCS/DSS where it is given an cursory review and then forwarded to the local county Medi-Cal agency (DPSS in most counties).

There have been some very bizarre happenings around the state, especially in Los Angeles County, where eligibility has yet to be determined for some families/individuals after more than 5-6 months following submission of their applications through CoveredCA.

Some folks have been asked to provide lists of assets, which is NO LONGER REQUIRED for persons ages 19-64 who do not need assistance with long-term care expenses, and then told they do not qualify as a result. This, too, is wrong.

If you have been denied/terminated from Medi-Cal, you can still file an administrative appeal through DHCS/DSS. I recommend that you do that immediately. If you need assistance, contact me.

I am paying insurance for my son & daughter. My daughter lives with her mother & has medical IEHP but when my son moved with me she canceled his medical leaving me to keep the ins. I provide them with. (Anthem blue cross) If he still qualifies for medical can i cancel his present ins. before applying. And how would i go about doing it?

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