‘A disaster waiting to happen’: Do staff shortages threaten Medi-Cal plans for renewing recipients?

In one report after another earlier this year, counties from Los Angeles to Sacramento warned Medi-Cal officials that they don’t have enough trained staff — or simply don’t know whether they do — to process the millions of Californians whose cases come up for renewal starting in June.

For three years now, ever since federal officials declared a public health emergency in March 2020, U.S. law has prohibited Medi-Cal from kicking millions of Californians off its rolls, even if their incomes pushed past eligibility limits.

The end of so-called continuous coverage will come over a rolling 12-month period, based on the last date when a Medi-Cal enrollee’s eligibility was determined. If enrollees don’t submit the proper documentation by time their eligibility month ends, they will lose their benefits.

State officials estimate that 2 million to 3 million Medi-Cal enrollees could lose coverage because counties can’t manage the volume of cases or they don’t have the right addresses for enrollees or they can’t get critical information in time.

Through a public records request, consumer advocate David Kane and his co-workers at the Western Center on Law and Poverty discovered just how woefully unprepared counties are for this undertaking. In reports to the California Department of Health Care Services, county welfare directors around the state cited challenges such as staff shortages, an unseasoned workforce, a new computer system and budget constraints.

Placer County officials, for instance, said in their assessment that “low staffing, inexperienced new staff, new state system and budget” were impediments they faced to preparedness, adding “Staff in general will be slow at processing renewals that have been rolling forward since beginning of the (public health emergency). Large caseloads.”

Fresno County reported: “Identified county doesn’t have sufficiently trained/experienced case managers to process renewals.”

Sacramento County officials stated: “Current staffing levels assigned to continuous case maintenance may not be adequate. Staff hired after 03/2020 may need additional ongoing support as they become familiarized with the renewal process.”

In Los Angeles County, officials said: “Anticipate needing additional staff. New eligibility staff may be slower at case processing. therefore this needs to be accounted for.”

Stanislaus County wrote that it “is experiencing low staffing levels, this will impact processing of renewals, follow up reviews, and restorations.”

“None of this works if county Medi-Cal offices don’t have what they need in terms of basic resources and people in their offices to help people renew their Medi-Cal because they are the ones who determine whether somebody qualifies or should be terminated,” Kane said. ”Today, with the historic level of record-high Medi-Cal enrollment, that already would be a challenge to counties and their offices, but it’s even worse. Counties have said they are understaffed and are constantly trying to fill vacancies. We’re really concerned that under these difficult circumstances, we’re not ready.”

Yingjia Huang, an assistant deputy director with DHCS, said that she and her peers have taken pre-emptive steps to reduce the volume of cases requiring county staff attention and have been providing technical training sessions, recording them to allow replay. And, she said, the department has $146 million appropriated to help counties with the cost of hiring personnel.

Cathy Senderling-McDonald, executive director of the County Welfare Directors Association, said that “counties have really been planning for the unwinding since the continuous coverage requirements went into effect in March 2020” but that they have been facing the same challenges recruiting staff as other employers in a tight labor market. For every two job openings in February 2023, there were 1.2 people looking for work, according to the US Bureau of Labor Statistics.

Consumer advocates fear widespread bottlenecks. Amy Collier Carroll an executive at Golden Valley Health Centers, which offers care to Medi-Cal enrollees across the Central Valley, said: “Everyone is sort of biting their nails. This whole unwinding process, as they’re calling it, is really going to be a doozy for a lot of people.”

Medi-Cal by the numbers

Medi-Cal covers health care expenses for more than 15.5 million Californians, a third of state residents. That’s up from 12.5 million in March 2020. The number includes senior citizens who have used up the lifetime limits for skilled nursing care and hospital stays through Medicare, children with complex medical conditions and many residents whose disabilities or illnesses prevent them from working.

Across the Central Valley, from Bakersfield to Sacramento, state and county health departments as well as local organizations are tasked with reducing the number of eligible families who fall through the cracks, but the barriers are high.

In total, the region has more than 3.1 million Medi-Cal recipients, including more than half a million people who have enrolled since March 2020. Certain populations are at high risk of losing their coverage.

An analysis by the US Department of Health and Human Services found that 72.2% of children risk losing their coverage despite being eligible. Latinos and families making below 100% of the federal poverty limit are also disproportionately at risk of losing Medi-Cal coverage.

Medi-Cal dread

Inexperience and ignorance can be costly for Medi-Cal enrollees, as Roseville resident Laurel Petersen found out. She said she has been dreading the day that continuous Medi-Cal coverage ends and she must once again apply for coverage for her son Lance.

His case will come up for renewal in September, she said.

No one provides a manual, in writing or online, that explains Medi-Cal rules, Petersen said, and she’s been shocked in the past by decisions that threatened her family’s financial security and an omission of information that could have improved it. Over time, she’s assembled a fat binder by requesting to see on paper the regulations that shaped cost or coverage decisions.

Petersen also has spent years learning about her son’s conditions and identifying providers who can manage them. He’s been diagnosed with a combination of developmental and psychological disorders: autism, an inability to pay attention, hyperactivity, and bipolar swings that manifest in flashes of extreme depression and manic bursts of energy.

Doctors have told Petersen that her son will always have the mentality of a 5-year-old. She funds her son’s health care needs through dual coverage, so Medi-Cal picks up almost all medical expenses that her employer-sponsored health insurance plan doesn’t pay.

For years, Petersen said, Lance received this safety-net Medi-Cal coverage without having to pay a share of the cost. Then, in October 2017, Medi-Cal told her she would have to pay $731 a month to continue coverage.

County officials told her that the child support she received from Lance’s father counted as her son’s income. If she and her ex had still been married, Petersen discovered, they would bear no share of costs.

Shocked by the size of this expense, Petersen did the math and realized she and her son would be better off financially if she quit working and instead became his care provider under California’s In-Home Supportive Services Program.

Her employer, however, didn’t want to lose her and gave her a raise that allowed her to cover Lance’s share of costs.

In 2021, Petersen said, she came across information explaining that the portion of the premium she paid to cover Lance on her employer-sponsored plan should have been deducted from Lance’s share of Medi-Cal costs.

She brought it to Medi-Cal official’s attention, and they lowered Lance’s share of cost to $413 a month. She said she still wonders why no one at Medi-Cal had noticed this, especially since she had told them she couldn’t afford to pay $731 monthly.

Wrong answers prove costly for enrollees

Having weathered such financial challenges from a system that seemed arcane and capricious even before the COVID-19 pandemic, Petersen said she’s anxious about how the changes in her life over the last three years will affect her son’s coverage and whether she’ll have a Medi-Cal caseworker with the knowledge base to effectively assist her.

Petersen said she has many questions and wonders whether she’ll get reliable answers:

Lance turned 18 last year. Will he be able to continue getting care from the pediatric specialists who have precisely dialed in his treatment, or will his mother have to search for adult specialists for him?

Lance has been on fee-for-service Medi-Cal his whole life, ensuring that he can access leading physicians, many of whom do not contract with managed care Medi-Cal plans. Will he have to move into an adult managed-care world, competing for a short supply of experienced professionals just as a three-year backlog of other children like him will be seeking the same specialized care?

Petersen’s friends have already warned her of the struggle to find specialists with the right credentials in the Medi-Cal managed-care networks. For Petersen, the task would be even more difficult because she would have to find specialists who accept not only the Medi-Cal managed care plan available in her county but also her employer-sponsored insurance plan.

After the pandemic began, Petersen also changed her insurance plan at work, lowering the premium taken out of her paycheck. How much will that raise Lance’s share of Medi-Cal costs?

And, since inflation has driven up the cost of just about everything, Petersen said, she’s preparing to seek an increase in child support for Lance. She’s not certain whether that will help or hurt their financial position, given Medi-Cal income rules.

In 14 years, no mail from Medi-Cal

While Petersen is anxiously awaiting receipt of a yellow envelope containing Lance’s renewal packet, consumer advocates fear that many Medi-Cal enrollees don’t know that continuous coverage is ending and won’t receive their notices to provide further information.

With funding from the Robert Wood Johnson Foundation, the nonprofit Urban Institute surveyed adults from families enrolled in Medicaid, the name used for Medi-Cal nationally. The research revealed that 64.3% of respondents had heard nothing about the return to regular Medicaid renewal processes as of December 2022. That figure was virtually unchanged from a June 2022 survey.

Monica Alvarado said she has never received mail regarding her Medi-Cal in the 14 years she has lived in West Modesto.

She manages the Medi-Cal enrollment for her whole family: her husband, her 5-year old twin boys, and her daughter Camila, who has Down syndrome and was born with a cleft foot that requires regular physical therapy. Her children’s belongings — car seats and tricycles for the twins, baby formula for Camila — pile up in the two-bedroom apartment she shares with her brother, who has epilepsy.

Before the COVID-19 pandemic, individuals needed to prove their eligibility for Medi-Cal once a year. In the past, Alvarado’s eligibility date fell in March. Every year in the weeks before it, she drove to the Stanislaus County Community Services Agency with evidence of her income and details about her family.

Days before her renewal date in 2020, the system changed as California and other states suspended the annual re-certification process to comply with federal laws for the public health emergency. In exchange, Congress sent billions of dollars in additional funds to cover the cost of continuous of care.

The trouble was that no one told Alvarado about this extension, so she made her annual trek to the county offices and found theme closed. She spent hours holding on the phone to get answers.

“I was like: ‘What’s going on? Why have I not received (anything)? How do I renew my Medi-Cal?”

Addresses have changed

Now, Alvarado said, she’s uncertain whether her next renewal is scheduled for March 2024, like it was before the pandemic, or in June, the month in 2020 when her eligibility was last renewed. “They said I’ll just get stuff when I get it in the mail,” she said, “if I do get mail.”

States and counties manage the Medi-Cal cases and renewals through an automated system known as CalSAWS, the California Statewide Automated Welfare System.

Months before the Petersens, Alvarados and other enrollees reach a renewal date, that system starts assessing whether it can use information on federal and state databases to automatically renew their coverage. Even though terminations were suspended, this so-called ex parte process continued amid the COVID-19 public health emergency.

Before the pandemic, 41% of households that receive other federal benefits such as CalFresh, the state equivalent of food stamps, were automatically recertified for Medi-Cal, which saved county agencies the difficult task of reaching out to families through mail or email.

But a report from the Department of Health Care Services, the agency with oversight of Medi-Cal, said that the number of people determined eligible for automatic renewals now hovers between 30% and 40%. In the pandemic years, the percentage dropped as low as 25% because CalSAWS could not verify critical pieces of data on many enrollees.

Huang said that DHCS had requested and received federal waivers to allow greater flexibility on income thresholds during the unwinding to lower the number of people needing county follow-up.

“We’re entering this period of record-high enrollment, and Medi-Cal seems like a disaster waiting to happen,” Kane said. “If things are not going right during the unwinding period …, we would see people being terminated from Medi-Cal for process or procedural reasons.”

What does ‘failure to cooperate’ mean?

Changes to income, employment or household size don’t qualify as processing or procedural problems, Kane said. So, what would? Let’s say Medi-Cal sends out a renewal packet but never gets a response, Kane said, that could qualify, as would a failure to get any response to queries for specific pieces of data.

DHCS spokeswoman Katharine Weir-Ebster said much of the information in current member case files and the verification sources are out of date and thus inconsistent with federal databases.

“If the information is inconsistent,” she said, ”there is a likelihood that the Medi-Cal member cannot be automatically renewed …, and the Medi-Cal local county office would need to reach out for additional information via a renewal packet.”

If the counties receive no response from mailings, it’s called a “failure to cooperate” in the language of Medi-Cal, Kane said. After a Medi-Cal outreach mailing yielded an avalanche of returned mail in December 2021, DHCS estimated that roughly 2 million people could lose coverage because they relocated and never updated their addresses.

Enrollees also report having to wait for hours on county phone lines to get help, Kane said, and they sometimes must hang up before they reach anyone. DHCS is going to provide a dashboard showing how the agency is doing at making contacts, he said, but they’re not reporting call center wait times.

Huang said people call the county lines for many reasons, so hold times won’t reflect only Medi-Cal calls.

While that’s true, Kane said, DHCS will be posting wait times for three offices that are not set up to handle Medi-Cal renewals. It makes no sense, he said, to include those and omit the lines that Medi-Cal enrollees actually use.

Kane urged Medi-Cal enrollees to update their information either in their online accounts or by phone to ensure their addresses are correct, and to be on the look-out for the yellow envelopes bearing renewal packets. These pre-populated questionnaires typically arrive about 75 days before Medi-Cal coverage ends, Kane said, so Californians with June renewal dates should receive the documents by mid-April.

Getting the word out to enrollees

Aware that this Medi-Cal enrollment period could result in upheaval for millions, state leaders have taken steps to mitigate the fallout. DHCS has been hosting weekly meetings with county agencies to exchange information and keep abreast of issues.

Gov. Gavin Newsom and state legislators put $25 million in the DHCS budget to enable Medi-Cal to develop an outreach and education campaign in multiple languages.

And, on Feb. 8, DHCS relaunched its Medi-Cal website, telling families to update their information so that they receive proper notices about their health care coverage. The state’s campaign came six weeks after the federal government officially passed legislation requiring states to restart annual Medi-Cal redeterminations.

DHCS also has recruited 1,700-plus volunteer “coverage ambassadors,” whom Weir-Ebster called “trusted messengers” in their communities, to share information about the upcoming Medi-Cal changes. Kane said he’s signed up as one.

Huang said the agency also has invested $60 million in a health enrollment navigators project within community-based organizations over four fiscal years to help counties connect with hard-to-reach populations eligible for Medi-Cal enrollment.

In Stanislaus County, nonprofit social services provider El Concilio adapted its annual $200,000 grant with the county to include placing phone calls to Medi-Cal beneficiaries, advising them to update their information and, now, telling them to prepare for the upcoming renewal process. Site supervisor Lynnette Lucaccini said El Concilio called 1,182 people in the first quarter of 2023. Stanislaus County has about 271,600 Medi-Cal recipients, according to the most recent state report.

Counties around the state are undertaking such novel partnerships because they are short-staffed, but Lucaccini said her team is finding that some Medi-Cal enrollees think it’s a scam.

“Those are all realistic fears,” she said, noting they always give them the county contact information. “We’ve had people say, ‘Well, Medi-Cal would never call.’”

Enrollment navigators at health centers around the state — whether they’re rural, community-based or federally qualified to receive enhanced Medi-Cal reimbursements — also are making an extra effort to ensure their patients have updated their information in the Medi-Cal system, said Laura Sheckler, a policy expert at the California Primary Care Association. Some clinics have received state funding to expand their effort.

“It is so complex, that just having somebody on your team who can help navigate the different changes that come up or what you might need or what new situations might look like,” Sheckler said. “I feel like having that sort of advocate, especially where you receive care, seems like such a critical component of this because it is such a complex system.”

DHCS also has partnered with the national change of address database and the U.S. Postal Service to forward letters to addresses in California without additional confirmation from enrollees. And since many frail, elderly California residents receive medical services from Medi-Cal’s Program of All-Inclusive Care for the Elderly, or PACE, DHCS also has arranged to use any updated contact information in that program’s database to reach participants.

Advocates want more outreach

Kane said these efforts are good, but it’s just not enough. He said that, because of extraordinary demand upon counties, the state should expand funding for navigation assistance provided by health centers, community-based organizations and others. Sheckler’s organization has asked lawmakers to boost navigator funding by $60 million for 2023-24.

In Colorado, the state is taking a high-tech approach to connecting with its enrollees, contracting with El Dorado Hills-based fintech company Intellaegis to use its software database to find people whose addresses have changed.

Intellaegis gets its information from a variety of sources — LexisNexis, Experian, Equifax, TransUnion, Thomson Reuter and the like, said John Lewis, the company’s chief executive officer..

Typically, customers come from the ranks of financial institutions, insurance companies and even law enforcement, looking to track down people that have no valid forwarding addresses with U.S. Postal Service, Lewis said. The company’s software also ensures that users comply with all data security and privacy regulations when making contacts.

The leaders of Colorado’s Medicaid program opted for Intellaegis’ masterQueue software program because it eliminated the need for spreadsheets and a lot of manual labor. They simply uploaded information on returned mail into masterQueue and received new addresses and phone numbers, streamlining the effort it took to find enrollees.

“It’s not easy to find people who are not necessarily wanting to be found or don’t have as much data out there as other people who are a little more stable,” Lewis said. “We know that because our software is used by not just prime lenders but also by subprime and deep-subprime, and some of the characteristics of a person who’s struggling financially a little bit on the lending side can be similar to the people who are maybe just struggling a little bit more with health insurance. They don’t have a job that provides them with great health care, so they’re on some form of government-assisted health care.”

A recent case study showed that with masterQueue, Colorado’s rate of reaching enrollees with whom it had lost contact rose to 17.5% from 5.9% in just two months, Lewis said, and this will help states renew cases at a higher rate without having to hire additional staff.

Not everyone currently on Medi-Cal’s rolls will still be eligible for coverage because many people have had changes in their income or families over the course of the pandemic, but the U.S. Department of Health and Human Services found that one-third of these individuals will qualify for subsidies through Covered California or other insurance marketplaces set up under the Affordable Care Act.

Recognizing this connection, California legislators passed Senate Bill 260 in 2019, ensuring that Medi-Cal enrollees whose income makes them ineligible will receive an automatic offer of a Covered California plan.

“We have always had a commitment to what we call ‘no wrong door,’ meaning if you come into Covered California, but your income makes you eligible for Medi-Cal, we get you to Medi-Cal and vice versa,” said Jessica Altman, the executive director of Covered California. “We have shared systems and technology and commitment and all of those things to really help with that back and forth.”

SB 260 makes this process more seamless and supportive for enrollees, Altman said, so once they are determined to be ineligible because of income, an offer letter will be sent to them.

Many people will likely have to pay no premium. About 90% of Covered California enrollees receive federal or state subsidies, Altman said, and a quarter of those individuals pay $0 in premiums. Nearly half pay $50 or less.

All they have to do is call or go online, accept the offer and choose a plan, Altman said.

The question remains, however, whether the offers will find enrollees because the Medi-Cal system has outdated contact information.

“We do expect to have not just email information,” Altman said, “but other contact information and we do expect that we will be doing, for example, outbound phone calls and those types of things within our resource capacity to try and reach those that we don’t seem to be connecting with just through the traditional electronic or physical mailing channels.”

Despite the challenges, Kane said, Medi-Cal has made some strides toward trying to stem the anticipated outflow of enrollees and leaders of the agency have long maintained an open line of communication with standing monthly meetings.

Department officials have moved on a number of suggestions, he said, to remove barriers and smooth re-entry to normal operations. For instance, he said, Medi-Cal regulations had for years prevented enrollees from renewing their coverage if their property and other assets topped certain financial limits.

This asset test was set to sunset starting in January 2024, Kane said, but that reprieve would have come too late for millions of Medi-Cal recipients renewing their coverage from June through December of this year.

Legislators and consumer advocates appealed to DHCS leaders to ditch the asset test when it resumes normal operations in June, Kane said, and the agency agreed, moving quickly to secure HHS approval.

So, Medi-Cal enrollees will no longer have to provide information on bank accounts, retirement accounts, property, and any other assets when renewing their coverage. Many seniors, Kane said, resorted to impoverishing themselves to continue getting medical services they didn’t have the cash to afford.

Still, Kane said there’s much work to do. He and other advocates would like to see Medi-Cal open the automatic renewal process to people who have disabilities and people who are aged 65 and older. Currently, they must call, go online or mail in renewal packets, he said, even though their information is less likely to change than that of many other Medi-Cal enrollees.

To ensure people understand what’s in the renewal packets, Kane said, the state also should send out the information in any of 19 languages for which it has translations.

“They’re holding back … six languages, so tens of thousands of people are not getting it in their language,” Kane said, “even though they have said, ‘Please send it to me in my language.’ It’s people who speak Hindi, Mien, Japanese, Punjabi, Thai and Ukrainian.”

Kane continued: “We want (DHCS) to do more. When they launched their big (marketing) campaign, the $25 million one, they released the materials in only English and Spanish, period.”

In California, where more than 15.5 million people are on Medi-Cal, Kane said, that means they excluded over a million people who speak other languages. It remained that way for more than a month before other languages were added.

Despite public appeals, efforts by coverage ambassadors and news reports, some enrollees will go to make an appointment with their provider or to get a prescription filled and then learn that their Medi-Cal coverage was discontinued.

If they’re within 90 days of their cut-off date, Kane said, Medi-Cal will pay for those medical expenses as long as they provide the information needed to renew their benefits within that 90-day period.

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