But there’s a catch: If people want to move to original Medicare and buy a supplemental Medigap insurance plan to cover some out-of-pocket costs, they may not be able to. Medigap insurers can generally refuse coverage to applicants whose medical history or current health problems might make them expensive to cover, a process called medical underwriting.

“We really want people to factor that in,” said , managing policy attorney at the Center for Medicare Advocacy. “If someone is in a Medicare Advantage plan for several years and then wants to switch to original Medicare, they may find they can’t switch and also get a Medigap plan.”

There are many reasons people might want to trade their MA plan for traditional Medicare. Although MA managed-care plans are typically cheaper and offer benefits not available in original Medicare, such as coverage for vision and hearing services, they have smaller provider networks than the original program and, sometimes, extensive prior authorization requirements.

In addition, as Medicare Advantage plan in recent years, a growing number of plans are pulling out of areas they used to serve, leaving members with fewer options. This year, an estimated 1 in 10 MA plan members will be forced out of their plans for this reason, according to a in February.

“We saw some Medicare Advantage plans that just left the market completely and stopped issuing plans,” said Emily Whicheloe, education director at the Medicare Rights Center.

For those considering a switch to original Medicare, getting a Medigap plan can be tricky. Federal law provides a one-time, for people 65 or older and newly covered by Medicare Part B to sign up for any Medigap plan without underwriting. After that initial sign-up period ends, however, there are fewer coverage guarantees.

But some do exist. Here are a few key circumstances and time frames when people are guaranteed a Medigap plan without having to undergo underwriting:

• People who live in Connecticut, Massachusetts, or New York can sign up for a Medigap policy without underwriting. In Maine, there is a one-month window each year when Medigap insurers must offer Plan A to all comers without underwriting. (Plan A provides less comprehensive coverage than some of the other standardized plan types.)
• People who sign up for a Medicare Advantage plan when they are first eligible for Medicare Part A at age 65 can switch to original Medicare within the first year and buy a Medigap plan too. This is sometimes called the “.”
• If a Medicare Advantage plan leaves Medicare or in an area, affected enrollees can switch to original Medicare and buy a Medigap plan either 60 days before or up to 63 days after their MA coverage ends. During this special enrollment period, they can’t be turned down or charged more based on their health.
• If an individual and no longer has access to their Medicare Advantage plan providers, they can switch to original Medicare and apply for a Medigap policy either 60 days before or up to 63 days after their MA coverage ends. That typically happens when someone notifies the plan of their permanent move or the plan discovers it, said , a training, policy, and technical assistance consultant at California Health Advocates who specializes in Medicare and Medigap coverage.

There are other circumstances when someone might qualify for a special enrollment period under federal rules, and states may have additional qualifying events that are more generous than federal standards.

Patient advocates emphasize that it’s often useful to work with a counselor at the , or SHIP, for free, unbiased help figuring out Medigap coverage options. SHIP counselors can help applicants identify potential avenues to qualify for Medigap coverage without underwriting at both the federal and state levels.

People who don’t qualify for a guaranteed right to a Medigap plan without underwriting may still be approved for coverage. Premiums may be higher, however, and plans may impose a waiting period of up to six months for coverage of preexisting medical conditions in certain circumstances.

Beware: More Underwriting

In recent years, some Medigap insurers have spent a growing percentage of premiums on medical claims, putting pressure on profits, Burns said. “Medigap insurers’ underwriting has tightened up considerably recently,” she said.

The list of health conditions that Medigap insurers might deny coverage for is long, including Alzheimer’s disease, asthma, cancer, congestive heart disease, diabetes with complications, end-stage renal disease, high blood pressure, and stroke, among others, according to a of leading insurers’ applications.

When people apply for a Medigap plan that will be medically underwritten, they will typically be asked to fill out a health questionnaire, said , a principal and consulting actuary at Milliman who is a Society of Actuaries fellow. Increasingly, insurers are requesting that people agree to a prescription drug background check, Ortner said.

“Oftentimes, that prescription drug history may be the primary driver of a decision as it relates to underwriting,” he said, rather than a physical exam or medical records review.

Insurers don’t all have the same underwriting rules, however. Here again, a SHIP counselor may be useful for pointing people to specific companies that accept applicants with a particular medical diagnosis, or have different waiting periods or coverage exclusions.

“They have access to a Medigap comparison tool in addition to what is existing on that can give you a very good estimate of what you may pay for those Medigap plans,” said , associate director of health coverage and benefits at the National Council on Aging.

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But the intense jockeying over the money is only beginning.

Top state health officials say they plan to plow most of the money into higher payments for doctors, hospitals, and other health care providers who serve Californians covered by Medi-Cal, the state’s Medicaid program. But the framework, hammered out this summer as part of state budget negotiations, lacks critical details, which has set off a lobbying frenzy among health industry groups seeking a cut.

Even as they battle for their share, industry leaders are quietly plotting a November 2024 ballot initiative to lock in the Medi-Cal payment increases, which they argue are needed to sustain the safety-net program that covers Californians — a staggering 40% of the .

“We are addressing decades of systemic underfunding in Medicaid that has exacerbated inequity and health care provider deserts, where patients are often forced to get their care in emergency departments,” said Dustin Corcoran, the CEO of the influential California Medical Association, which represents doctors.

Corcoran also leads the coalition negotiating with Gov. Gavin Newsom and fellow Democratic lawmakers in Sacramento over how the money — a combination of state and federal funding to be doled out over six years — will be spent.

“Even with this historic deal, there are still parts of the health care system that are going to struggle to provide the care that patients need,” Corcoran said. “The coalition is dedicated to ensuring long-term stability and predictability in reimbursement rates in California.”

California has among the lowest Medicaid reimbursement rates in the country, which is often cited as a key reason many low-income patients can’t get care and often face excruciating wait times, especially for primary care, obstetric, and mental health appointments, said Kathryn Phillips, the associate director for improving access to care at the California Health Care Foundation. (Ñî¹óåú´«Ã½Ò•îl Health News publishes California Healthline, which is an editorially independent service of the California Health Care Foundation.)

“That’s where the state is struggling the most,” she said. “Low rates are why a physician may not accept Medi-Cal patients, or only accept a low number of patients.”

This deal funds the largest increase in base Medi-Cal reimbursement rates in , said Jennifer Kent, a of the state Medicaid agency.

The money will come from the managed care organization tax, which has been levied since 2005 on health insurers that do business in California. Revenue from the tax, which allows the state to secure billions in federal health care dollars it wouldn’t otherwise receive, has previously been funneled into the state general fund, which can be used for anything state leaders want.

Under the deal, and for the first time, Newsom and the legislature have agreed to use the money to improve care for poor Californians. Of the $19.4 billion projected to be raised by the tax between 2023 and 2026, $11.1 billion will go directly to Medi-Cal and $8.3 billion to the general fund to offset state spending on Medi-Cal, according to state Department of Finance spokesperson H.D. Palmer.

The new funding will start flowing next year, with $820 million earmarked for initial rate increases in primary care, obstetric care, and mental health care, Palmer said.

From 2025 through 2029, the state plans to allocate nearly a year, according to the department. State and industry officials said they plan to direct some of the money to expand medical residency programs for doctors serving low-income people, fund new beds for psychiatric patients, and increase the workforce of other providers such as nurses, mental health therapists, and community health workers.

But the bulk will go to rate increases for primary care and an array of providers and services, including hospitals and long-term care facilities, abortion care, and emergency services. Higher rates for specialists, such as psychiatrists and dentists, are also desperately needed.

Although Newsom and state health officials have promised to direct the money to health care providers, they haven’t specified which ones will get increases — and there’s no guarantee the money won’t be diverted to another program. Medi-Cal, a massive and ballooning program with a budget of $152 billion this fiscal year, is under tremendous pressure. The state continues to expand the program to more people and offers a growing list of expensive services, despite the threat of budget deficits.

“There has to be more guardrails,” said Assembly member Vince Fong (R-Bakersfield) during a June legislative debate. “This should not be seen as a revenue grab.”

Mark Ghaly, Newsom’s health and human services secretary, acknowledged that even though some providers and treatments may be left out initially, the payment boosts represent a critical step toward better access.

“The core providers in Medicaid will benefit,” Ghaly told Ñî¹óåú´«Ã½Ò•îl Health News. “There’s always going to be someone out there with a question and a concern, and I hope that as we learn about them and we hear them, we address them.”

Ghaly said the tax will bring some Medicaid rates in California from the bottom in the country to the top. While he acknowledged concerns that the money might be diverted in future years, he said Newsom is committed to spending it on Medi-Cal. “Who knows about the uncertainty of the future?” he said. “But we have basically done as much as you can to hard-wire these changes into the way we design Medicaid. The man with the pen — the governor of California — is committed to this.”

Even though the tax deal isn’t big enough to fix all the problems in Medi-Cal, it will improve patient care, said Charles Bacchi, president and CEO of the California Association of Health Plans, which represents private and public insurers.

“There’s a lot more work to do hammering out the rate increases and where they should go,” Bacchi said. “We have to make sure that the funding actually survives the budget process next year.”

Some providers worry they may be left out.

“We’ve argued hard for optometrists to be included,” said Kristine Schultz, executive director of the California Optometric Association, noting that optometrists can’t afford to treat poor patients because of low rates. For example, optometrists get about $39, on average, to conduct an eye exam on a new Medi-Cal patient, while Medicare reimburses $158, she said.

As a result, she said, patients “are not able to get in for months.”

Ann Rivello, a therapist in San Mateo County specializing in trauma, also cited low rates — and complicated medical billing demands — as the reasons she doesn’t accept Medi-Cal patients.

“I’ve been practicing over 20 years and I do not accept Medi-Cal even though it’s within my values,” she said.

Detailed rates for most health care treatments for Medi-Cal patients are not publicly available because they are negotiated privately by insurance companies and vary by geography and health insurance plan. And the state has a slew of bonus payments it uses to supplement base Medi-Cal rates, further obfuscating how much health care providers receive.

While Medi-Cal rates vary widely, on average, California reimburses 76% of Medicare rates, Phillips said. Next year, the state plans to raise that base payment rate to 87.5% of Medicare in three target areas — primary care, obstetrics, and mental health.

As health care providers battle for their slice of the tax revenue, they say they want to avoid the same lobbying fight each time the state renews the tax, which happens every few years. One option they are considering: a ballot initiative next year that would lock the Medi-Cal funding into the state constitution.

Bacchi declined to take a position on the concept but said insurers are “taking a look at it.” He argues that California “needs to make a long-term commitment to the Medi-Cal program.”

John Baackes, the CEO of L.A. Care, the largest Medi-Cal insurer, supports the idea. He argues that a permanent increase in Medi-Cal rates would help address the disparities between Medi-Cal and private insurance coverage.

“The pandemic showed us that inequality is a life-and-death matter, because if you look at the people who got sick the most and died, they were people of color,” he said. “If we continue to ignore that, we’re idiots.”

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The Coalition to Protect Access to Care, which includes groups representing doctors, hospitals, insurance companies, and clinics, is and his fellow Democratic lawmakers on allocating proceeds from a tax on health insurance companies. The governor earlier this month nearly $820 million from renewing the Managed Care Organization, or MCO, tax to boost Medi-Cal reimbursement rates and divert $8.3 billion to the state general fund, leaving $10.3 billion up for grabs.

Each sector has its own idea of how that money should be spent, even as the health care industry presents a unified front, according to interviews with hospital leaders, health insurance executives, doctor groups, and community clinics. The coalition also wants to cement higher Medi-Cal funding into the state constitution, potentially through a ballot initiative in November 2024.

“We are actively exploring a plan to provide permanent and predictable funding, and stability, in the health care system,” said Dustin Corcoran, CEO of the California Medical Association, who confirmed talks with other industry groups and health care advocates about an initiative.

Medi-Cal, a massive safety-net program, has timely, comprehensive health care and adequately meet the needs of 15.8 million low-income and disabled Californians who depend on it. Hospitals, clinics, and other health care providers say reimbursement rates fall short of the cost of their services.

“Health care has eluded patients for a long time,” Corcoran said. “This is absolutely a generational opportunity to improve Medi-Cal and ensure that patients can access care whenever they need it.”

California is among more than a dozen states that levy taxes on managed care organizations, a type of health plan, to draw in extra federal health care money for Medicaid. California adopted the tax back in 2005 and it has been renewed five times, according to state Department of Finance spokesperson H.D. Palmer. The last version, which expired in December, .

However, the tax revenue has never been dedicated for new initiatives in Medi-Cal and Newsom wants to change that, such as by paying providers higher rates for primary care, mental health and addiction treatment, and maternity care.

While health groups and lawmakers agree on propping up Medi-Cal and raising reimbursement rates, various sectors of the health industry are positioning themselves to benefit from the portion still up for grabs. Hospitals say they are especially deserving of a large share of the $10.3 billion in revenue but have not indicated how they want the money distributed.

“It’s not that every other player isn’t important,” said Carmela Coyle, the president and CEO of the California Hospital Association, which is lobbying Newsom and lawmakers for a broad bailout even though not all hospitals need help. “But we did take the lion’s share of the hit during covid.”

Corcoran, of the California Medical Association, which represents doctors, contends that all providers who serve Medi-Cal patients should benefit, not just one type. “The tax has to deal with the entire ecosystem of health care,” he said. “You can’t just focus on a particular part of it.”

Insurers say they are still mulling over support of the tax, arguing it should benefit all Medi-Cal patients. In California, health insurance companies agreed to be taxed by the government, which brings in extra federal dollars to plug holes in Medi-Cal. Health insurers don’t get the money back directly. Instead, the money is spread across the entire health care system.

“We don’t just run around supporting new taxes. It’s not an easy decision,” said Charles Bacchi, the president and CEO of the California Association of Health Plans, which represents public and private insurers in the state. “For the health plans that have to add this tax to their premiums, it needs to be affordable for our customers.”

Newsom and lawmakers are hoping to agree on the tax by the . However, negotiations on how to spend the money could continue well into summer and perhaps even next year.

Newsom wants to levy the tax through 2026 and spend the money over an eight- to 10-year period. But health providers and consumer advocates want it spent over roughly three years. The Newsom administration argues that stretching the money over 10 years protects against potential federal health care rule changes that could result in less revenue for California.

“We’ve spread those dollars out for a long period of time to provide sustainability and longer-term fiscal certainty to our providers,” Michelle Baass, director of the state Department of Health Care Services, which administers Medi-Cal, told lawmakers last week.

Health industry groups, community clinics, and patient advocates are pushing back, arguing there is always federal uncertainty. They say Medi-Cal, which has undergone major expansions, including to cover , needs an infusion of money now.

“We should invest today because the need is so high,” said Francisco Silva, president and CEO of the California Primary Care Association, which represents community clinics that overwhelmingly serve low-income patients.

Anthony Wright, executive director of Health Access California, industry groups and the administration to come up with a deal addressing disparities by targeting all the money to improve patient care and promote more equitable access to doctors.

“Frankly, your experience in the Medi-Cal program is really different around the state — county by county, plan by plan,” Wright said, arguing investments must be made “in those areas where there are real problems.”

Doctors and insurance industry leaders are arguing to use the $10.3 billion for even higher Medi-Cal rates, and health plans say specifically there should be bigger rate increases for specialty care and loan forgiveness for doctors in underserved areas.

Community clinics, which offer one-stop care, want more payments that reimburse them each time a patient shows up for care rather than bundling them into one visit for one fee. And public hospitals are eyeing the revenue to offset their projected losses from caring for a disproportionate share of low-income people. The Newsom administration wants to raise Medi-Cal rates for hospital emergency room and outpatient visits, Baass told lawmakers.

If health interests can strike an agreement, it’s an opportunity for them to secure and direct billions in spending as they see fit. But the coalition could also splinter.

“It needs to be done in a way that’s fair to everybody,” said Democratic state Sen. John Laird of Santa Cruz, who sits on the budget committee. “The worry is that everybody wants a piece of it.”

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Mike Randol took over May 31 as head of Montana’s Medicaid program, which serves who live in low-income households or have disabilities in a state of 1.1 million people. The program has a roughly $2.3 billion annual budget, with the federal government picking up about 80% of the total.

Randol most recently was an executive with Cerner Corp., which provides health information technology services. Before that, he led Medicaid programs in Kansas and Iowa, both of which hired national management firms to administer benefits, instead of having state employees do it.

“I’m a firm believer in managed care,” Randol told reporters in 2019 as he defended the Iowa program at a news conference announcing an 8.6% annual increase in the rate the state would pay its two management companies.

Montana health department spokesperson Jon Ebelt declined to say whether Randol’s hiring signals that Montana plans to privatize management of its Medicaid programs.

Adam Meier, director of the Montana Department of Public Health and Human Services, said in a statement that he looks forward to working with Randol to better serve Montana Medicaid recipients. “Mike is a proven leader with vast experience in overseeing state Medicaid programs,” Meier said.

The health department declined requests to interview Meier and Randol. Ebelt declined to provide copies of Randol’s application for the job, saying the documents are confidential.

Managed care got a bad reputation in Montana after to manage Medicaid-covered mental health care in the 1990s. The state eventually took back management after numerous patient and provider complaints and after the company, Magellan Behavioral Health, cut provider rates to make up for the loss of millions of dollars in its first year. In 2011, widespread opposition led the state to scrap plans for a managed-Medicaid .

Under managed Medicaid, the state and federal governments pay insurance companies a set amount of money per enrollee to cover health care services. If the companies can do so for less money than they are paid, they pocket some of the difference as profit. All but 11 states, including Montana, have privatized at least part of their Medicaid programs, .

Randol became the Medicaid director in Kansas in 2012, the year before it . Those who backed the change said privatization helped control costs, while critics said it reduced program coverage and transparency.

Iowa Gov. Kim Reynolds, a Republican, hired Randol in 2017. His arrival in Des Moines came about two years after Iowa switched to a private Medicaid management system, which was plagued by complaints that Iowans with disabilities had been and that the management companies lost in the initial years.

When Randol resigned in 2020, Reynolds praised his service: “I am so thankful for the work he’s done to not only stabilize the program, but improve the system, incorporate technology, and set a foundation that we can build on moving forward.”

Deb McMahon, an Iowan who became a vocal critic of Medicaid privatization because of her family’s experience with it, said that if she lived in Montana, she would view Randol’s hiring as a sign the state intends to outsource its program to management companies. “His record speaks for him,” she said.

Vulnerable Montana residents who rely on Medicaid could see major disruptions if the system is privatized, McMahon said. “Their services, the people they count on to help them — all that will change,” she said.

McMahon said that when Randol was in Iowa, he was fond of citing statistics and talking about algorithms. But, she said, he seemed to become irritated when members of the public described how Medicaid changes affected people.

McMahon’s 41-year-old daughter, Annie Stender, has an intellectual disability and uses Medicaid-financed services. Before Iowa’s Medicaid system was privatized, Stender had the same case manager for 15 years, McMahon said. That person knew her well and helped her navigate the array of services.

But under private Medicaid management, Stender has been assigned to several case managers. “We lost that bond,” McMahon said. “We lost that person in our lives.”

, executive director of the Behavioral Health Alliance of Montana, said that Randol’s past in Kansas and Iowa “doesn’t really give us a warm, fuzzy feeling.”

Windecker said she worries a managed-care comeback would lead to lower reimbursement rates for medical providers. She said she’d be surprised if Montana doesn’t consider some form of privatization, in part because of how many other states have done so. “What we’re hoping is, regardless of the model that the state looks at, the providers will be at the table,” Windecker said.

Randol is arriving ahead of a massive review of Medicaid enrollees’ eligibility for the program. Enrollment has increased steadily since the pandemic began, and the federal public health emergency imposed during the covid-19 pandemic has paused routine reviews. When the emergency order ends, certain Montana beneficiaries will likely experience to keep their coverage into the future.

Health advocates have said people who meet coverage requirements could unintentionally be dropped in the process.

Heather O’Loughlin, co-director of the , said that as new leadership takes over, she hopes the priority will be helping people maintain access to their coverage. “This is not a time for political ideology, but an opportunity to listen to health care providers, tribal leaders, rural residents, and those facing barriers in health care to ensure this transition is as smooth as possible,” O’Loughlin said in a statement.

State legislators also are in Montana in response to a shortage of providers and services, beginning with the mental health system. Health providers have long said Medicaid reimbursements fall well below the cost of operating. A program-wide review is expected to take years.

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Hace unas semanas, los reguladores estatales impusieron una multa récord de a L.A. Care, el plan de atención administrada de Medi-Cal más grande de California, por no garantizar una atención adecuada y por permitir retrasos en el tratamiento que amenazaban la salud de los beneficiarios.

Defensores de pacientes esperan que la medida indiqueÌý que, de ahora en más, habrá una aplicación más estricta contra otras aseguradoras de Medi-Cal, que tienen muchas de las mismas deficiencias por las que los reguladores acaban de multar a L.A. Care.

Veinticinco planes de atención administrada en todo el estado brindan atención a de los más de 14 millones de californianos inscritos en Medi-Cal, y con frecuencia se acusa al estado de no responsabilizar a los planes por una atención deficiente. Los miembros de Medi-Cal se encuentran entre las personas más vulnerables del estado: pueden enfrentar barreras idiomáticas y culturales, y tienen tasas desproporcionadamente altas de enfermedades crónicas.

El Departamento de Servicios de Atención Médica (DHCS, en inglés) del estado, que administra Medi-Cal, está redactando de atención administrada, programado para entrar en vigencia en 2024, que según funcionarios mejorará la atención al exigir estándares más altos a los planes de salud participantes. El estado espera reducir las disparidades de salud y mejorar los resultados de salud al reforzar la vigilancia y el cumplimiento.

“Están tratando de hacer más, y eso es realmente positivo”, dice Abbi Coursolle, abogada senior del en Los Ángeles. “Obviamente, tienen mucho más que hacer”.

El DHCS y el Departamento de Atención Médica Administrada del estado, que también regula los planes de atención médica administrada de Medi-Cal, iniciaron investigaciones coordinadas de L.A. Care, basadas en parte en que destacó demoras prolongadas, a veces mortales, en la atención en las instalaciones administradas por el Departamento de Servicios de Salud del Condado de Los Ángeles. Esa agencia opera el sistema de red de seguridad pública del condado y tiene un contrato para brindar atención a cientos de miles de miembros de L.A. Care. En sus investigaciones, los reguladores estatales también se basaron en la información que les proporcionó L.A. Care (mismo).

El hecho de que confiaran en estas fuentes, dice Coursolle, plantea dudas sobre la eficacia de su propia vigilancia y auditoría.

El 4 de marzo, el Departamento de Atención Médica Administrada impuso a L.A. Care una multa de $35 millones, más del triple de su multa anterior más alta. El Departamento de Servicios de Atención Médica recaudó $20 millones, casi ocho veces su récord anterior.

El estado citó a L.A. Care por más de 100,000 infracciones, incluidas respuestas tardías a las quejas y apelaciones de los pacientes, autorizaciones demoradas o denegadas para atención médica necesaria y la falta de garantía de que la agencia de servicios de salud del condado cumpliera con las normas de atención al paciente. El Departamento de Salud Pública de California, que regula los hospitales y otras instituciones de atención médica, no respondió a una pregunta sobre si está investigando alguna de las instalaciones médicas del condado.

Al anunciar estas multas, los directores de las agencias estatales dijeron: “La magnitud de las violaciones de L.A. Care, que han resultado en daños para sus miembros, requiere una acción inmediata”. El plan de salud tiene 2,4 millones de beneficiarios de Medi-Cal.

“La reciente acción contra L.A. Care indica que el DHCS tiene la intención de ejercer su autoridad para proteger a nuestros beneficiarios de Medi-Cal”, me dijo Anthony Cava, vocero del departamento, en un correo electrónico.

John Baackes, director ejecutivo de L.A. Care, dice que el plan no cuestiona los hallazgos. “Lo que estamos cuestionando es el monto de las multas, que creemos que no son razonables”, dijo Baackes. La disputa podría tardar meses, o incluso años, en resolverse.

En un comunicado emitido después que se anunciaran las multas, L.A. Care señaló los pagos notoriamente bajos de Medi-Cal a los proveedores y dijo que las sanciones crean “otro obstáculo financiero más para un plan de salud pública que es una parte crucial de la red de seguridad de la atención médica”.

Aunque L.A. Care ha generado millones de dólares en ganancias en los últimos años, reportó una pérdida de en el año fiscal 2020. Pero el plan puede sortear las multas. A fines del año pasado, su patrimonio neto tangible, una medida clave de solvencia, era que el mínimo requerido por ley.

Las violaciones descritas por los reguladores son dolorosamente familiares para Theresa Grant, una residente de Culver City sobre la que escribí a fines del año pasado y que de un dolor debilitante en su caja torácica. Las violaciones son “horrorosas”, dice, “y creo que es muy cierto”.

Pero Grant cree que los médicos especialistas que no han podido o no han querido ayudarla tienen gran parte de la culpa. “Sabes cuánto tiempo he estado lidiando con mi problema”, me dijo. “Ha pasado más de un año y no se está haciendo nada”.

A pesar de las sanciones significativas impuestas a L.A. Care, los defensores de los consumidores y algunos legisladores estatales creen que California necesita la autoridad para imponer sanciones aún mayores.

Un proyecto de ley patrocinado por el grupo de defensa del consumidor aumentaría muchas de las multas que los reguladores estatales de planes de salud pueden imponer en al menos diez veces. Los partidarios dicen que la legislación, , es necesaria porque la cantidad que el departamento puede imponer legalmente a los planes de salud no ha aumentado, en algunos casos, desde 1975.

“Queremos asegurarnos de que las compañías de seguros no vean estas multas solo como el costo de hacer negocios”, dice el autor del proyecto de ley, el senador estatal Scott Wiener (demócrata de San Francisco). “Al aumentarlas, se vuelven menos un costo comercial y más un incentivo real para cumplir con la ley”.

Las multas impuestas a L.A. Care son atípicas debido a su magnitud, determinada en parte por la gran cantidad de infracciones. “Por cada multa como esa, hay muchas que son dramáticamente más bajas”, dice Wiener. “No me gustaría depender de un solo caso y decir: ‘Oh, no hay problema, porque recibieron una gran multa’”.

Wiener agrega que otro factor importante para mantener la presión sobre los planes de salud son las quejas de los consumidores, que pueden ayudar a llamar la atención de los reguladores, y de los propios planes, sobre los problemas.

Pero mostró que las apelaciones de los consumidores por atención denegada son extremadamente raras.

Si tienes un problema con su plan de salud o quieres apelar una demora o denegación de cobertura, un buen lugar para comenzar es el Departamento de Atención Médica Administrada (888-466-2219 o ).

El estado también tiene un ombudsman para la atención administrada de Medi-Cal (888-452-8609 o MMCDOmbudsmanOffice@dhcs.ca.gov ).

También puedes probar (888-804-3536 o ), que ayuda a las personas con planes de salud públicos y privados. Ofrece asesoramiento gratuito, brinda servicios legales, y puede ayudarte a preparar los documentos para una apelación.

Tanto los reguladores como los planes de salud dicen con frecuencia que están trabajando en nombre del paciente. Entonces, si no estás recibiendo la atención que necesitas, levántate y sé parte de la solución.

Esta historia fue producida por KHN, que publica , un servicio editorialmente independiente de la .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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A few weeks ago, state regulators imposed a on L.A. Care, California’s largest Medi-Cal managed-care plan, for failing to ensure adequate care and allowing treatment delays that threatened enrollees’ health. Patient advocates hope the move signals stricter enforcement against other Medi-Cal insurers, which have many of the same shortcomings for which the regulators just fined L.A. Care.

Twenty-five managed-care plans across the state provide care for of the more than 14 million Californians enrolled in Medi-Cal, and the state is often accused of failing to hold the plans accountable for subpar care. Medi-Cal members are among the state’s most vulnerable people: They can face language and cultural barriers and have disproportionately high rates of chronic illness.

The state Department of Health Care Services, which runs Medi-Cal, is drafting a new , scheduled to take effect in 2024, that officials say will improve care by holding participating health plans to higher standards. The state hopes to reduce health disparities and improve health outcomes by tightening surveillance and enforcement.

“They are trying to do more, and that’s really positive,” says Abbi Coursolle, senior attorney at the in Los Angeles. “Obviously, they have a lot more to do.”

DHCS and the state Department of Managed Health Care, which also regulates Medi-Cal managed-care plans, launched coordinated investigations of L.A. Care, based in part on a that highlighted long, sometimes deadly, delays in care at facilities run by the Los Angeles County Department of Health Services. That agency operates the county’s public safety-net system and contracts with L.A. Care to provide care for hundreds of thousands of the health plan’s members. In their investigations, state regulators also relied on information that L.A. Care reported to them.

That they relied on these sources, Coursolle says, raises questions about the effectiveness of their own surveillance and auditing.

On March 4, the Department of Managed Health Care hit L.A. Care with a $35 million penalty — more than triple its highest previous fine. The Department of Health Care Services levied $20 million, nearly eight times its earlier record.

The state cited L.A. Care for more than 100,000 violations, including late responses to patient complaints and appeals, delayed or denied authorizations for necessary medical care, and failure to ensure the county health services agency complied with patient care regulations. The California Department of Public Health, which regulates hospitals and other health care institutions, didn’t respond to a question about whether it’s investigating any of the county’s medical facilities.

In announcing the fines, state agency directors said: “The magnitude of L.A. Care’s violations, which has resulted in harm to its members, requires immediate action.” The health plan has 2.4 million Medi-Cal enrollees.

“The recent enforcement action against L.A. Care signals that DHCS intends to exercise our authorities to protect our Medi-Cal enrollees,” department spokesperson Anthony Cava told me in an email.

L.A. Care’s CEO, John Baackes, says the plan is not contesting the findings. “What we are contesting is the amount of the fines, which we believe are unreasonable,” Baackes said. The dispute could take months, or even years, to settle.

In a statement released after the fines were announced, L.A. Care noted Medi-Cal’s notoriously low payments to providers and said the penalties create “yet another financial hurdle for a public health plan that is a crucial part of the health care safety net.”

Although L.A. Care has generated millions of dollars in profits in recent years, it reported a in fiscal year 2020. But the plan can weather the fines. At the end of last year, its tangible net equity — a key measure of solvency — was as high as the minimum required by law.

The violations described by regulators are painfully familiar to Theresa Grant, a Culver City resident I wrote about late last year who has from a debilitating pain in her rib cage. The violations are “horrific,” she says, “and I think it’s very true.”

But she believes the specialist physicians who have been unable or unwilling to help her deserve a big share of the blame. “You know how long I’ve been dealing with my problem,” she told me. “It’s been over a year now, and not a damn thing is being done.”

Despite the significant penalties levied on L.A. Care, consumer advocates and some state lawmakers think California needs the authority to levy even larger ones.

A bill sponsored by the consumer advocacy group would increase many of the fines that state health plan regulators can impose at least tenfold. Supporters say the legislation, , is needed because the amount the department can legally levy on health plans hasn’t been raised in some cases since 1975.

“We want to make sure that insurance companies do not view these fines as just the cost of doing business,” says the bill’s author, state Sen. Scott Wiener (D-San Francisco). “By raising them, they become less a cost of business and more an actual incentive to follow the law.”

The fines imposed on L.A. Care are outliers because of their size, which was determined in part by the sheer number of violations. “For every fine like that, there are many that are dramatically lower,” Wiener says. “I wouldn’t want to rely on one case and say, ‘Oh, no problem, because they got a big fine.’”

Another important factor in holding health plans’ feet to the fire, Wiener says, is consumer complaints, which can help bring problems to the attention of regulators — and to the plans themselves.

But a by KFF showed that consumer appeals of denied care are exceedingly rare.

If you have a problem with your health plan or want to appeal a delay or denial of coverage, a good place to start is the Department of Managed Health Care (888-466-2219 or ).

The state also has an ombudsman for Medi-Cal managed care (888-452-8609 or MMCDOmbudsmanOffice@dhcs.ca.gov).

You can also try the Health Consumer Alliance (888-804-3536 orÌý), which assists people in public and private health plans. It offers free advice, provides legal services, and can help you get your documents in order for an appeal.

Regulators and health plans alike frequently say they are working on behalf of the patient. So if you’re not getting the care you need, stand up and be part of the solution.

This story was produced by , which publishes , an editorially independent service of the .

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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The , introduced Jan. 26 by the powerful Georgia House Speaker , a Republican, is focused on improving the state’s mental health care system.

Tucked inside the legislation is a provision that would require the Medicaid managed-care companies to refund payments to the state if they don’t spend enough on medical care and quality improvements for patients.

Georgia Health News and KHN reported in September that Georgia was one of only a few states that doesn’t mandate a minimum level of medical spending for its Medicaid insurers.

Each year, Georgia pays three insurance companies — CareSource, Peach State Health Plan, and Amerigroup — a total of more than $4 billion to run the federal-state health insurance program for low-income residents and people with disabilities. For 2019 and 2020, the companies’ combined profits averaged $189 million per year, according to insurer filings reported by the National Association of Insurance Commissioners.

“Instead of ensuring adequate health care networks for Georgia’s children, Georgians with disabilities, and Georgians in nursing facilities, hundreds of millions of dollars go instead to the Georgia [insurers’] bottom lines,” said Roland Behm, a board member for the Georgia chapter of the .

Behm, who advised lawmakers on the bill, said the KHN and Georgia Health News article helped bring the issue to the attention of legislators crafting the bill.

Georgia is among more than 40 states that have turned to managed-care companies to run their Medicaid programs — and ostensibly control costs. According to an August report from the U.S. Department of Health and Human Services’ Office of Inspector General, 36 of those states and the District of Columbia set a benchmark “medical loss ratio” for the minimum spending by insurers on medical care. Besides Georgia, the report said, the five states not requiring a managed-care spending threshold were Kansas, Rhode Island, Tennessee, Texas, and Wisconsin.

Republican state Rep. Todd Jones, a co-sponsor of the new bill, told KHN that Georgia lawmakers should establish a strong benchmark for insurers to meet. “We should look at what other states are doing,” he said.

Most states with a spending requirement set that ratio at a minimum of 85% of premium dollars that insurers are paid. So when a Medicaid insurer spends less than that on medical care and quality improvements, it must return money to the government.

The Georgia bill also calls for setting the threshold at 85%. If the bill is approved, the Medicaid insurers would face the medical spending requirement in 2023.

If the benchmark had been in place in recent years, it could have forced a recoupment from the Peach State company, which has the largest Georgia Medicaid enrollment of the three insurers. State documents show it failed to reach the 85% mark from 2018 to 2020, KHN previously reported.

, a research professor at Georgetown University’s Center for Children and Families, called the 85% mark “a win for taxpayers, for Medicaid providers, and for Medicaid beneficiaries.” He also said it would be more than fair to the Medicaid insurers, which could keep 15% of what the state pays them for administrative costs and profit.

Because Ralston is the lead sponsor of the bill in the House, it’s expected to pass that chamber.

But the insurance industry likely will work to remove the medical spending provision.

An industry official, Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group, declined to comment on the legislation.

Fiona Roberts, a spokesperson for the state Department of Community Health, which oversees the Medicaid program, said the agency needs time to review the measure before commenting on it.

The main provisions of the bill require insurers to provide coverage for mental health care or substance use treatment at the same level as other physical health needs.

The legislation would provide education loan support for people training in the fields of mental health and substance use disorders and seek to expand behavioral health services for children. It would also facilitate “assisted outpatient treatment” — when a judge could order a person with a serious mental illness to follow a court-ordered treatment plan in the community.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Now 2 years old, Markeano is attached to breathing and feeding tubes. He can’t walk or move his arms.

“If I want him to sit up, I have to sit him up. If I want him to play with a car, I’ve got to put his hand on the car and move it back and forth,” said Williams, 38, who lives with Markeano, her four other children and her husband, Marcus, in Adelanto, California, a small city in the High Desert region of San Bernardino County.

Markeano is enrolled in the Inland Empire Health Plan, a county-run managed-care insurer that provides coverage under Medi-Cal, California’s version of the federal Medicaid program for people with . He also receives care through , which covers kids with serious conditions.

But Williams still finds it difficult to get her son the specialized care he needs. What’s worse, neither his insurers nor his doctors take responsibility for managing his care, she said. “No one coordinates the care except for me.”

Poor care coordination is one of the many shortcomings of Medi-Cal, which covers over a third of the state’s population and Advocates, patients and even the state auditor say Medi-Cal has failed to hold accountable the managed-care health plans that cover almost 12 million of its nearly 14 million enrollees.

To remedy these failings, the state has begun an ambitious contracting process that aims to commit the health plans to better service. The state’s exact strategy is unclear. But it is expected to result in new rules for Medi-Cal managed care. The nine commercial insurers, including giants Health Net, Anthem Blue Cross, and Blue Shield of California, will have to bid for new contracts intended to set more rigorous care standards. While their members account for fewer than one-third of managed-care enrollees, the companies have made nearly $3 billion from Medi-Cal since 2014.

Non-commercial plans like the Inland Empire Health Plan, which are established by county authorities, won’t have to submit bids, but they will be required to sign the new contracts.

“The state has had a lot of difficulty — because of skill and will — in managing and enforcing the terms of its existing contracts,” said Alex Briscoe, head of the California Children’s Trust and former director of Alameda County’s Health Care Services Agency. “This represents an opportunity not only to redesign the contracts but also to reimagine the state’s role in enforcing them.”

It’s also an opportunity for the state to make a statement in selecting plans.

“Some are doing worse than others, and that should be taken into account in terms of decisions as the plans bid,” said Edwin Park, a California-based research professor at the Georgetown University Center for Children and Families.

Jacey Cooper, California’s Medicaid director, said the state’s focus will be assuring that plans provide access to care and are committed to improving the outcomes of Medi-Cal beneficiaries.

The recontracting process is intertwined with an to move Medi-Cal beyond medicine into the realm of social services.

‘Deficient Oversight’

Data shows that Medi-Cal plans are failing enrollees in many ways. Patients often have long waits or travel times for medical appointments, and get fragmented services and poor information about their care. , as well as rural residents, receive lower-quality service than others.

Faulty treatment hits the 4.6 million kids in managed-care Medi-Cal particularly hard because children need a lot of routine care, and many are not getting it. In July, close to 500 advocacy and provider groups sent a to the Department of Health Care Services, which runs Medi-Cal, urging it to make the managed-care plans improve pediatric care. “The deficiencies in the Medi-Cal managed care program contribute to health disparities for children across the state that can last a lifetime,” they wrote. The new contracts, the letter said, should require health plans to fix the problem.

Federal law provides significant protection for all children in Medi-Cal and other state Medicaid programs. It for regular checkups, immunizations, and other preventive and diagnostic care.

But shows that Medi-Cal managed-care plans often fail to meet these requirements. Only about one-quarter of infants and toddlers in Medi-Cal get the recommended number of well-child visits and screenings for developmental delays. The plans fall short on immunizations as well.

A 2019 by the California State Auditor ranked California 40th among state Medicaid programs in use of preventive services by children.

The report blamed the state’s poor performance on “deficient oversight of the managed care plans” and an insufficient number of health care providers willing to accept Medi-Cal’s low payment rates.

“I don’t see how we can have a high-performing Medi-Cal system that doesn’t do well on those basic services for kids,” said Mike Odeh, health policy director at , an Oakland-based advocacy group.

To be fair, Medi-Cal has had its share of successes, too, including early and robust expansion of enrollment under the Affordable Care Act, extension of coverage to large numbers of immigrants without legal documents, and pioneering programs that address not only medical and mental health but also the social and environmental circumstances of enrollees.

Nonetheless, Medi-Cal managed-care plans often earn poor to mediocre marks for the quality of their care. Meanwhile, the largest commercial plans have profited handsomely from the program, especially since the . That helps explain why the rebidding process is such a sensitive matter for them. Health Net, Anthem Blue Cross, Molina Healthcare and Blue Shield of California all declined to discuss their bidding strategies with KHN.

Collectively, the commercial plans have generated $2.9 billion in net profits from Medi-Cal since fiscal year 2014, according to . Health Net, the state’s largest commercial Medi-Cal insurer, with around 2 million enrollees, accounted for $2.1 billion of that amount. Anthem Blue Cross, the second-largest commercial Medi-Cal plan, with 1.3 million enrollees, accounted for $873 million.

An Anthem Blue Cross spokesperson noted that Medi-Cal managed-care plans are required by law to spend at least 85 cents of every dollar on medical care or efforts to improve care. That, along with other factors, limits the health plans’ profits, he said.

Kaiser Permanente, which is at or near the top of Medi-Cal quality scores, has lost money in the program every year since 2014 — and before that, too.

Health Net and Anthem Blue Cross get poor to mediocre marks on key pediatric services in many counties, according to state data. Health Net Medi-Cal plans in Sacramento, Kern, Stanislaus and San Diego counties, for example, were at or near the bottom of the pack in of pediatric appointments.

A Health Net spokesperson said the company has improved over the past two years and now outperforms its competitors on state quality indicators in nine of the 13 counties where it operates.

The 2019 state audit, citing earlier concerns about incomplete and inaccurate reporting, noted that the integrity of the state’s quality data can be hard to assess.

And non-commercial plans often have low scores, too. “Quality is stubbornly low across all plans in Medi-Cal. Nobody gets a pass here,” said Cary Sanders, senior policy director at the California Pan-Ethnic Health Network.

The state rarely holds any of the plans fully to account, advocates and Medi-Cal experts say. The Department of Health Care Services started for poor quality only in 2017, and since then it has levied only two such fines: one against Health Net for $335,000 and one against the publicly run Health Plan of San Joaquin for $135,000.

The department does require subpar performers to devise so-called corrective action plans, but critics say they rarely produce significant improvement.

Even if enforcement were effective, the standards for Medi-Cal plans are too low, advocates say. Until 2019, insurers needed to be only in the 25th percentile of Medicaid plans nationally to avoid corrective action. The department raised the bar to the 50th percentile in 2019 but has not enforced it so far because of the covid-19 pandemic.

The department next year will begin penalizing any health plan that “fails to exceed, rather than just meet” the minimum performance level on any measure, said Cooper, the state’s Medicaid chief. It will do so every year, rather than target only persistently poor performers, she said.

Pay for Performance

In June, the Department of Health Care Services released preliminary details on the bidding process, outlining some of the new requirements. It expects to issue more details by year’s end but won’t announce plan selections until the end of 2022. The new contracts are slated to take effect Jan. 1, 2024.

But will the state lean hard enough on the plans? Based on the documents released so far, this could be a “potential missed opportunity,” said Sanders. “There aren’t enough teeth here to improve health plan accountability.”

Other advocates cite what they say has been a cozy relationship between health plans and the state. “I just think the whole delivery system has historically been filled with a lot of politics, favoritism, good old boys,” said Isabel Becerra, CEO of the Coalition of Orange County Community Health Centers, whose members provide Medi-Cal services in the county.

Some advocates and analysts say the best way for the state to hold the managed-care plans’ feet to the fire is to tie the fixed monthly rates it pays them to their performance on a number of measures, including preventive services and health equity.

“If you want to change how they work, you have to change the incentives that drive them,” said Briscoe, of the California Children’s Trust.

Medicaid chief Cooper said her staff is working to link payment to quality and health equity.

Some advocates say the state should withhold payments from poorly performing plans. The plans, however, would prefer being rewarded for exceeding expectations to being dinged for failing to meet them.

A Communication Breakdown

The rebidding process is expected to reduce the number of insurance companies participating in Medi-Cal — and some experts say that’s a good thing.

“The idea of competition is you’re supposed to be competing on the basis of quality, but if there are too many choices beneficiaries aren’t able to discern the differences,” said Georgetown University’s Park.

In some regions, the Medi-Cal health plans that contract directly with the state outsource care and administrative tasks to other plans or physician groups. L.A. Care, for example, farms out enrollees to subcontractors such as Kaiser Permanente, Anthem Blue Cross and Blue Shield of California. The Department of Health Care Services says that in evaluating the bids it will look favorably on health plans that commit to keeping closer tabs on their subcontractors.

The state reports quality scores only for plans with which it contracts directly, and their data can be skewed by wide variation in the performance of the subcontractors.

Moreover, the divided responsibility between health plans and their subcontractors can confuse beneficiaries.

“The subcontractor says, ‘No, call the plan’ — and the plan says, ‘Call the subcontractor,’ and there’s really no accountability,” said Abigail Coursolle, a senior attorney at the National Health Law Program in Los Angeles.

Denise Williams faces a similar problem. She said the Inland Empire Health Plan does not communicate effectively — or at all — with California Children’s Services or Markeano’s doctors. As a result, she is saddled with hours of legwork to find care for her son, whether speech, swallowing and cognitive therapy or extra oxygen tanks to make sure he doesn’t run out during long car trips to see his doctors.

“They tell me, ‘Your pediatrician or neurologist should be doing this.’ Then when I talk to the pediatrician and the neurologist, they say, ‘Talk to your insurance,’” Williams said. “So it’s like, ‘I already talked to you guys. Can’t you guys talk to each other — or can we get on a three-way? Because this is draining. I’ve got a kid that I need to take care of.’”

Inland Empire Health acknowledged the gaps in coordination among managed-care plans, California Children’s Services and providers, saying it was “eager to embrace the care coordination improvements” that the state says it will require. The new contracts also will require plans to address some of the nonmedical problems that can compromise health, such as inadequate housing, unclean air and water, and food insecurity.

In addition to being predominantly poor, of Medi-Cal enrollees are from non-white communities that have historically been socially and economically marginalized — which is why the state says it will put a high priority on reducing health care inequities.

Denise Williams, who is Black, wonders if her travails are related to long-standing inequities.

“Sometimes I don’t know if it’s because of my color or what,” she said. “I try to remain calm at all times, so that way it’s not a stereotype of an angry Black lady or whatever. But at the same time, I’m my kid’s only advocate, so if I never say nothing, my kid would just be lying in the bed all day.”

California Healthline correspondent Angela Hart contributed to this report.

This story was produced by , which publishes , an editorially independent service of the .

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Five kids still live at home, and all of them came to the Austins through the foster care system. All told, they see 14 doctors.

Many states promise to provide health care to help foster and adoptive families keep kids healthy, but recently in Illinois, thousands of children temporarily lost coverage when the state switched their health plans. Some of Rebecca and Bruce’s children got caught in the coverage gap, which has the Austins wondering whether the state will fulfill its end of the bargain.

Three of the Austins’ children see psychiatrists. One has regular visits with specialists for epilepsy and other health conditions. Another has therapy four times a week for movement and speech delays.

“A typical day is pretty crazy,” Rebecca Austin said in an interview before the coronavirus shelter-in-place orders were issued. “I say I’m a stay-at-home mom, but with all the doctors’ appointments and therapies and appointments and stuff, I’m on the go all the time.”

Their lives are full and busy already, and Austin is concerned Illinois’ health plan change will make juggling health care even more of a challenge.

The Austins live in Windsor, a rural town about 25 miles from the nearest hospital in Charleston, Illinois.

Since February, the state has been moving all current and former foster children covered by Medicaid into health plans provided by private insurers that contract with the state.

It’s a change to what’s known as . The shift has many families like the Austins concerned, because the initial phase of the rollout was rocky and because it’s not clear whether familiar, nearby health care providers will be designated as in-network.

More States Move To Managed CareÌý

already use managed-care companies to run their Medicaid health plans, which means state agencies pay insurance companies to provide health care to people in the Medicaid program.

Proponents of the managed-care model say it can lower costs while increasing access to care.

States that switch to managed care often find their budgets become more predictable, because they no longer pay providers for each service. Instead, they pay insurers a set amount per enrollee for all health care needs.

But Michael Sparer, a health policy professor at Columbia University in New York City, said as to whether managed care lowers costs and increases access to care. Success depends on whether states hold insurers to their promises to maintain an adequate provider network, he said.

“ refers to a health plan’s ability to deliver the benefits promised by providing reasonable access to enough in-network primary care and specialty physicians, and all health care services included under the terms of the contract,” according to the National Association of Insurance Commissioners.

Sparer said success with Medicaid managed care also hinges on whether states “have the ability and have the oversight that’s required to make sure that the program works effectively.”

In recent years, Illinois switched most of the state’s Medicaid enrollees into . Former foster children moved onto those plans on Feb. 1, and current foster children are set to eventually join them. The switch was initially planned for April 1, but the state has postponed the move for at least 30 days, citing the COVID-19 pandemic.

whether the move is in the children’s best interests.

Many foster children have serious physical and mental health needs, and the switch could disrupt long-standing relationships with therapists and other providers, critics of managed care argue.

For thousands of families like the Austins, this means figuring out whether their children’s providers will still be in-network or whether they’ll have to use new doctors, who might be farther from home.

Austin said her family found a managed-care plan that allowed them to keep most of their children’s providers. But when the February switch was finalized, the Austin children were among the 2,500 former foster kids whose health coverage was interrupted.

The “end date” for her kids’ coverage had been incorrectly listed in the computer system as Jan. 31 — one day prior to the coverage start date, Feb. 1, Rebecca said. This effectively left them without insurance. State officials blamed a glitch in the system for the error.

John Hoffman, a spokesman for the Illinois Department of Healthcare and Family Services, said in a statement that the agency worked with managed-care organizations “immediately to correct the error, resolving it within days.”

For the Austins, the error meant they had to cancel appointments and had problems getting prescriptions filled.

“My daughter who has epilepsy, her medicine was … a little over $1,000,” Austin said. “I didn’t have $1,045 to pay her for the medicine and, so, we were in a panic as to what to do because she had to have the medicine.”

Phone calls to pharmacies and insurers were onerous, she said, but she ultimately resolved the issue. Still, the Austins’ youngest, 4-year-old Camdyn, missed two weeks of therapy sessions, while they waited for the new insurer to approve them. Austin worries these delays will slow his progress.

Making Medicaid Managed Care Work

Heidi Dalenberg is an attorney with the , which serves as a watchdog for the state’s child welfare agency. She said managed care can be beneficial, helping ensure all kids get regular well-checks and prevent doctors from overtreating or overmedicating children.

But those benefits will be realized only if the state has prepared for the transition and holds insurance companies to their contract requirements, she said. That includes ensuring managed-care organizations, or MCOs, have appropriate provider networks so children have access to doctors close to home.

“When it doesn’t work is when you have an MCO that is more worried about cutting costs and denying approvals for care than they are in making sure that kids get what they need,” Dalenberg said.

A retired federal judge is monitoring Illinois’ efforts to ensure foster children don’t lose access to care in the switch to Medicaid managed care, Dalenberg said.

Hoffman, the state DHS spokesman, said the switch to managed care, provided by the insurer YouthCare Illinois, will help improve health care for current and former foster children by coordinating and providing services.

“Right now, when a family needs a provider for their child, they’re left to navigate a complex system alone,” Hoffman said in a statement. “With YouthCare, families have a personal care coordinator who helps manage their overall care, researches providers and schedules appointments.”

He said the problems caused by February’s glitch have been resolved and will not resurface when 17,000 current foster children eventually get switched into managed-care plans as well.

The Austins’ foster daughter will be among them. And Austin worries her daughter will be forced to switch to a therapist an hour’s drive away, since the one she sees nearby is not in the managed-care network.

“She has established a relationship with that counselor. She’s been going there for almost two years and now we have to start all over again,” Austin said. “And that’s trauma. That’s a huge trauma.”

Illinois said even providers that are not in-network when the switch goes into effect can be paid for services during a six-month “continuity of care” period, and insurers will try to expand their networks during that time.

The Austins are trying to be optimistic, but the state’s track record doesn’t give them much assurance.

This story is part of a partnership that includes , Illinois Public Media, Ìýand Kaiser Health News.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Pero entrevistas con docenas de terapeutas de Kaiser Permanente, pacientes y expertos de la industria pintan un cuadro preocupante de mejoras superficiales que se ven bien en el papel, pero que no se traducen en una atención más efectiva y accesible. Muchos pacientes todavía tienen dificultades para acceder al tratamiento, a menudo esperando dos meses entre sesiones de terapia.

Los terapeutas de Kaiser dicen que la HMO sabe cómo jugar con el sistema establecido por los reguladores de California para medir el progreso sin mejorar significativamente la atención. Describen un modelo que se basa en entrevistas superficiales, realizadas desde centros de llamadas, para mostrar una mejora en los tiempos de respuesta a los pacientes que buscan la primera cita, pero luego no cumplen con la atención de seguimiento en tiempo y forma.

“La primera cita no es comenzar el tratamiento. Sólo significa que el paciente tiene que explicar su experiencia varias veces”, dijo Kirstin Quinn Siegel, terapeuta matrimonial y familiar licenciada de la clínica de Kaiser en Richmond. “No es una manera de mejorar el servicio de salud mental. Es una forma de mejorar sus números”.

La situación ha provocado una huelga de cinco días, en la semana del 16 de diciembre, que involucra a miles de profesionales de salud mental de Kaiser que exigen más tiempo para tareas administrativas, salarios más altos y tiempos de espera más cortos para las citas de los pacientes.

Según varios terapeutas, una preocupación particular es un programa de telesalud llamado “Connect 2 Care”. A los pacientes que llaman con un problema de salud mental se les ofrece una cita, a veces ese mismo día, para una evaluación de admisión realizada por teléfono con un terapeuta.

Las llamadas de admisión, que duran aproximadamente 30 minutos, cuentan para cumplir con la regulación estatal de “acceso rápido”, que requiere que los pacientes reciban una cita inicial urgente en 48 horas y una cita no urgente antes de 10 días. Pero una entrevista de admisión estándar suele durar al menos una hora y la realiza en persona un terapeuta que debe establecer un tratamiento, según la Asociación Americana de Psicología. Estas visitas generalmente incluyen un historial médico completo, una evaluación del estado mental, un diagnóstico inicial y establecer un tratamiento.

En contraste, Kaiser ha abierto grandes centros de llamadas en Livermore y San Leandro donde los terapeutas de “Connect 2 Care” hacen la primera consulta por teléfono. Los pacientes hablan con estos terapeutas sólo una vez. Para programar una cita de seguimiento, a menudo esperan de cuatro a ocho semanas para ver a un terapeuta en persona que les proporcionará atención continua. Cuando finalmente llegan a ver a alguien, dijeron Siegel y otros, el paciente cuenta su historia de nuevo, y el nuevo terapeuta tiene que hacer otra evaluación. Muchos pacientes reportan meses de espera entre cada cita.

Cuando pregonan mejoras en la atención de salud mental, funcionarios de Kaiser señalan que el sistema cumplió con el requerimiento de acceso rápido del estado en más del 90% de los casos en 2019. Pero los terapeutas dicen que programas como “Connect 2 Care” tienen más que ver con la buena burocracia que con la buena medicina.

Michael Torres, psicólogo infantil de la clínica San Leandro, señaló que cuando se trata de terapia continua, poco ha cambiado en los 17 años que ha trabajado en Kaiser. Su agenda es tan apretada que puede ver a sus pacientes sólo cada cuatro a seis semanas, incluso cuando un niño sufre una depresión severa y debiera recibir atención semanal. “Es desgarrador”, dijo. “Los casos empeoran, se prolongan los síntomas, y profesionalmente no es ético”.

Torres también tiene un consultorio privado, donde dice que algunos de sus pacientes de Kaiser eligen verlo con más frecuencia pagando de su bolsillo. “Entonces, los que obtienen mejores servicios son los que pueden pagarlo”, agregó.

Kenneth Rogers, psicólogo de Kaiser en el área de Sacramento, explicó que sus opciones son ver a sus pacientes una vez cada dos meses o apretarlos después del horario regular. “No importa en qué trabajes, en ocho semanas pierdes mucho. Para la mayoría de los pacientes, se necesita un seguimiento regular”, apuntó.

“Yo le digo a la gente que, si tienen problemas serios de salud mental, no vayan a Kaiser”, expresó Augie Feder, terapeuta que dejó Kaiser el año pasado y tiene un consultorio privado en Berkeley.

Mientras que las quejas sobre el cuidado inadecuado de la salud mental siguen siendo comunes en todo el sistema de salud de Estados Unidos, Kaiser, con sede en Oakland, ha sido objeto de un escrutinio particular por parte de los reguladores de California en los últimos años, en parte porque sus terapeutas han sido agresivos a la hora de documentar los problemas.

En 2013, el Departamento de Atención Médica Administrada del estado descubrió que Kaiser estaba afectando sistemáticamente a los pacientes que buscaban tratamiento de salud mental en violación de la ley de paridad del estado, y les impuso una multa de $4 millones. En 2015, los reguladores citaron de nuevo a Kaiser y descubrieron que algunos pacientes esperaban meses para ver a un psiquiatra o terapeuta. En 2017, el estado citó a Kaiser por tercera vez ante la persistencia de los problemas. Esta vez, las partes llegaron a un acuerdo que requería que Kaiser contratara a un consultor externo por tres años para mejorar el acceso y la supervisión.

Desde entonces, el Sindicato Nacional de Trabajadores de la Salud, que representa a 3,600 terapeutas de salud mental de Kaiser en California —incluyendo psicólogos, terapeutas de pareja y familiares, trabajadores sociales y enfermeras psiquiátricas— ha seguido enfrentándose a Kaiser por lo que el sindicato considera fallas continuas.

“Kaiser se limita a hacer que cumple”, dijo Fred Seavey, director de investigación del sindicato. Pero aún no hay suficientes terapeutas para satisfacer la demanda de los pacientes, señaló, y añadió que, a pesar de los $79,700 millones de ingresos operativos en 2018, Kaiser utiliza un “modelo de austeridad” en el que el sistema raciona la atención mediante la distribución anticipada de recursos para las citas iniciales a expensas de la atención continua.

Según una entre 759 terapeutas de Kaiser en abril, el 71% dijo que los tiempos de espera para las citas en sus clínicas había empeorado en los últimos dos años; sólo el 4% dijo que las citas semanales individuales estaban disponibles para los pacientes que las necesitaban. El sindicato ha recopilado de pacientes que afirman que no han podido acceder a una atención de salud mental adecuada.

En una carta de septiembre a la Asociación Americana de Psicología, Kaiser acusó al sindicato de llevar “una campaña de presión pública… para presionar a la gerencia de Kaiser Permanente a que aceptara sus demandas económicas”.

“Nos esforzamos como el que más por solucionar este asunto nacional”, explicó el doctor Don Mordecai, psiquiatra y líder nacional de Kaiser Permanente en salud mental y bienestar. “Somos conscientes de nuestros retos”, dijo. Los índices de depresión, ansiedad, suicidio y adicción se han disparado en todo el país en los últimos años, y ha sido difícil satisfacer la demanda, agregó.

Además, dijo Mordecai, existe una escasez de trabajadores de salud mental que retrasa la contratación. Kaiser ha aumentado su fuerza laboral de salud mental en California en un 30% desde 2015, pero la membresía ha crecido un 23% durante el mismo período, provocando un cambio insignificante en la proporción de pacientes por terapeuta. El programa “Connect 2 Care” ofrece a los pacientes acceso rápido a un profesional de salud mental, señaló Mordecai, y las encuestas muestran que la satisfacción de los pacientes es alta.

Kaiser ha lanzado una iniciativa para capacitar a 140 terapeutas al año y ha asignado $10 millones para ampliar su programa de formación de posgrado. También ha contratado a proveedores externos, incluyendo Beacon Health Options y Magellan Health, para mejorar el acceso a la atención.

Mordecai dijo que parte del problema es la mentalidad de que todos los pacientes con depresión o ansiedad deben recibir terapia individual a largo plazo. “Eso está pasado de moda”, apuntó. “Nunca habrá suficientes proveedores para hacer eso”. En cambio, argumentó, muchos pacientes con problemas moderados de salud mental deberían recibir tratamiento en un espacio de atención primaria.

En contraste con la encuesta sindical, el vocero de Kaiser, Vincent Staupe, dijo que una revisión de las visitas posteriores a la primera evaluación encontró que se atiende a los pacientes más del 84% de las veces, según las recomendaciones documentadas de los terapeutas.

Pero varios terapeutas de Kaiser dijeron que el sistema de registros electrónicos que genera esa estadística es engañoso.

“Si le dices eso a un terapeuta en cualquier clínica de Kaiser se asombrará, porque no es cierto”, dijo Siegel, de la clínica de Kaiser en Richmond. “Prácticamente no hay un terapeuta que vea a sus pacientes tan a menudo como recomiendan”.

Cuando los terapeutas introducen la fecha de la próxima cita de un paciente en la plantilla del sistema de registros médicos electrónicos, por ejemplo, aparece en la lista de “opciones de tratamiento recomendadas”, cuando la fecha se basa realmente en la disponibilidad de citas, comentó Siegel.

“Según ese lenguaje parece que el terapeuta recomienda que el paciente regrese en cuatro, seis u ocho semanas, algo que un médico casi nunca recomendaría”, aseguró Siegel.

Siegel dijo que los terapeutas en Richmond y en otros lugares están insertando su propio lenguaje que especifica la frecuencia de las citas clínicamente apropiadas (generalmente semanales o quincenales) antes de escribir la fecha de la “próxima cita disponible”.

Cuando se le preguntó sobre el tema, Marc Brown, vocero de Kaiser, dijo: “Tenemos numerosas plantillas dentro del registro de salud mental, y cambian constantemente para hacerlas más útiles”. Reiteró que las recomendaciones son determinadas y registradas “únicamente por los médicos”.

Los pacientes contactados por Kaiser Health News describieron la frustración de tratar de obtener ayuda a través de Kaiser Permanente: llamadas a terapeutas en vano, horas en espera, meses de tratamiento retrasados.

Matthew Wasserman contó que estaba “encantado de unirse a Kaiser” cuando se inscribió en enero de 2019. “Escuché que la atención médica era excelente, pero todos me dijeron que la de salud mental era muy mala”, dijo Wasserman, de 36 años, residente de Los Angeles.

Wasserman sufre de ansiedad y sabía que unirse a Kaiser significaba renunciar a las citas semanales con su terapeuta de toda la vida. Llamó a Kaiser una semana después del comienzo de su cobertura para hacer una cita. Después de una cita inicial, se le dijo que el seguimiento sería dentro de tres a cuatro meses. Y que alguien de Beacon Health se pondría en contacto.

Wasserman esperó más de una semana, pero nadie llamó. Empezó a contactar con terapeutas en el directorio en línea de Beacon. De los 30 a 40 que llamó, cinco devolvieron la llamada. Tres no podían atenderlo. Los otros dos tenían tiempo al mediodía, pero Wasserman no podía faltar al trabajo.

Así que llamó a Beacon y esperó casi dos horas al teléfono. Dos semanas después, recibió un correo electrónico con una lista de tres proveedores adicionales. Ninguno devolvió su llamada.

“Sufro de ansiedad, así que encontrar tiempo en el trabajo para llamar y revisar toda la información sobre mi atención de salud una y otra vez, fue muy duro”, aseguró Wasserman.

Sólo después de presentar una queja oficial, Kaiser encontró un terapeuta que podía verlo de forma continua. Habían pasado casi cuatro meses desde su solicitud inicial.

Para otros pacientes, las consecuencias han sido más extremas.

En junio de 2017, Kevin Dickens, de Alameda, estaba deprimido, ansioso y suicida. “Mi esposa llegaba a casa y me encontraba acurrucado en un rincón”, contó Dickens, de 42 años. Su médico de atención primaria le recetó Prozac, pero Kaiser dijo que no tenía citas de terapia disponibles.

En su lugar, se le envió una lista de 20 proveedores contratados. “Me tomó dos semanas repasar la lista, y todos los médicos me rechazaron”, dijo. Llamó a Kaiser y le enviaron otros 20 nombres, pero de nuevo no pudo conseguir una cita.

Dickens llamó por tercera vez y consiguió cita con un psiquiatra tres semanas después, casi nueve semanas desde su solicitud inicial. Fue a la cita, pero tres días después intentó suicidarse y fue hospitalizado.

Después de recibir el alta, Kaiser lo puso en contacto con un terapeuta que podía verlo cada seis semanas. “Sentí que necesitaba cada dos semanas”, contó. “Pero no había nada que pudiera hacer”.

La Asociación Americana de Psicología no hizo comentarios sobre el modelo de Kaiser Permanente. Pero Lynn Bufka, directiva de la organización, dijo que todos los estudios sobre la eficacia de la terapia se basan en citas que se realizan al menos una vez a la semana. “Por lo tanto, se plantea la cuestión de si la psicoterapia puede ser efectiva cuando se ve a alguien cada cuatro o seis semanas”, apuntó Bufka.

Shelley Rouillard, directora del Departamento de Atención Médica Administrada de California, dijo que su departamento aún no ha analizado si los pacientes pueden acceder a las citas de seguimiento y aseguró que tendrá más información después de una próxima encuesta. Aun así, añadió, Kaiser ha hecho mejoras desde 2017 y ha cumplido con las pautas establecidas en el acuerdo de conciliación. No quiso compartir detalles, argumentando que éstos no se hacen públicos.

“Eso no significa que los pacientes no tengan problemas para obtener servicios”, indicó Rouillard. “Eso sucede en todo el sistema de salud”.

El acceso a una terapia ambulatoria asequible sigue siendo un problema nacional.ÌýUn informe reciente de Milliman, una consultora de salud, encontró que los estadounidenses eran dramáticamente más propensos a recurrir a proveedores fuera de la red para la atención de salud mental que para otras condiciones debido a redes de proveedores inadecuadas.

Pero dado el dominio que tiene Kaiser del mercado en California, y su reputación como un modelo de atención integrada, los críticos del sistema dicen que las continuas deficiencias en la atención de salud mental son tan perjudiciales como inaceptables.

“Lo que les preguntaría a los ejecutivos de Kaiser es, ‘¿enviarías a un ser querido a nuestra clínica? ¿Querrías que a un familiar con depresión severa o ansiedad debilitante o alguna otra condición de salud mental se le diera cita una vez cada seis u ocho semanas?’”, expresó Siegel. “Seguro que no. Creo que querrían que sus seres queridos recibieran más tratamiento del que somos capaces de proporcionar”.

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