How Medicaid insurer rollout left some out

John McNeal

Director of the State Council for Persons with Disabilities

In January, 40,000 Delawareans on Medicaid began an insurance plan run through the new managed care organization Delaware First Health – with some being completely unaware of the change.

State officials said all of these residents are still enrolled in Medicaid and no one should face any disruptions in care. But that does not appear to be the case.

Delaware Online/The News Journal spoke with Medicaid recipients who say their providers denied them services due to their new insurance. Now some have to wait days – or weeks – to see their doctors, undergo necessary testing or resume an aide coming to their homes.

Annette Giffear, who described herself as experiencing a mental crisis, said she is in the midst of a tumultuous divorce. When she logged on for her weekly therapy session in early January, her therapist told Giffear she couldn't see her because of Giffear's new insurance.

"Here I am dying to talk to my therapist," Giffear said. "Because I'm on the brink of: 'Do I die or do I live?' And I could not talk to her and I can't talk to her this week."

This change has left Delawareans, who are low-income and have disabilities, in an even more vulnerable position, said John McNeal, director of the State Council for Persons with Disabilities. McNeal is among those who say they unknowingly were enrolled into Delaware First Health.

"This rollout was completely and utterly disastrous," he said.

'A great lack of transparency'

In July, the state health department announced it awarded a contract to Delaware First Health to become the third managed care organization to operate the state's Medicaid program.

The state wanted to add another managed care organization to its Medicaid program so there was "another dimension" of access to providers in Delaware, said Ted Mermigos, acting director of the Division of Medicaid & Medical Assistance.

More MCOs, he said, will also create more choices and competition.

As part of the state's agreement with Delaware First Health, Mermigos said, Delaware automatically enrolled 40,000 Medicaid recipients who were either on Highmark Health Options or AmeriHealth Caritas. It was a "random selection" of people, he said.

Mermigos said phone calls were made in both September and October, informing Medicaid recipients of open enrollment. Members also, he said, received a letter in October informing them of the MCO they were enrolled in.

The people assigned to Delaware First Health received a call in October, as well, while the state extended open enrollment to Nov. 15.

None of the people interviewed for this story said they received any phone calls or letters in the fall.

Mermigos acknowledged communication issues and the frustrations many Delawareans now feel.

"Are there areas that we could have done better about how we communicated with the members? Absolutely," he said. "We certainly don't want to add another layer of bureaucracy or confusion. We want to be there and be able to help them maneuver through this."

John Whitelaw, advocacy director of Delaware Community Legal Aid Society, said lawyers have been fielding phone calls over Delaware First Health. People have gotten paperwork or notification from providers in recent weeks that they don't understand.

"From what we've heard from our clients and from the documents we've seen," he said, "we think there was a great lack of transparency."

He noted that one client received a call the night before a scheduled surgery, informing her the procedure was canceled because of the change in insurance.

Whitelaw also questions what was done for people who aren't proficient in English. State officials said all communications were available in English and Spanish.

McNeal, of the state council, received a letter from Delaware First Health in the mail in late December − but he said he thought it was junk mail.

The letter, a photo of which was reviewed by The News Journal, included his insurance card. It didn't include any information about switching back to his old plan.

During the first week of January, McNeal was told by his provider that his health aide could no longer come to his home in the morning due to his new insurance.

McNeal, who is quadriplegic, describes his aide as "vital."

He immediately started making calls to his state contacts, which he realizes many people cannot do. It was straightened out, and he never faced any disruption in care. He remains on Delaware First Health.

A health department spokeswoman said the state does not have the total number of those who have switched back to their prior MCO because people have 90 days from Jan. 1 to switch their plans. People can also change their plans year-round for different reasons.

It wasn't until Jan. 18 that McNeal got a phone call informing him of the change that went into effect on Jan. 1, he said. He recalled the caller ID on his phone appearing as "Scam likely."

McNeal said the State Council for Persons with Disabilities was "extremely surprised" to only recently learn about this new MCO. The state organization, he said, has a legislative mandate to review policy, legislation and regulations.

The council did not review anything related to Delaware First Health, McNeal said. It plans to further investigate this issue.

"With all due respect to the leadership at the DHSS ... this is not a minor hiccup," he said. "The impact that this had on thousands of people across the state is extremely alarming.

"I can only imagine the trauma it created."

'I need help'

John Porter lives alone in his Wilmington apartment. Following a serious accident years ago, he suffers from a brain injury. He also has heart and hearing issues.

He relies on a home health aide to come to his apartment and help him every day. But Porter has been without an aide for about a month. He said he was told by both doctors and his home health aide provider that they don't accept Delaware First Health.

He first learned about Delaware First Health when he received the insurance card in the mail, but he didn't think it would affect his care.

Because he is switching back to AmeriHealth, he said he wouldn't be able to have his aide return or see his doctors until Feb. 1. He has pushed back important doctors' appointments.

"The little things I can do and can't do – it hurts me," Porter said. "So when they messed me all up, it frustrates me to do it by myself. I wind up snapping.

"It's set me back. I'm in here bugging. ... I need help."

Mermigos, the acting Medicaid director, said state officials sent an email to providers on Jan. 20 informing them how to sign up for the Delaware First Health network and that claims can be sent to Delaware First Health for patients who are now enrolled in the MCO.

He said Delaware First Health was primarily doing outreach for five months leading up to Jan. 1. The state is now helping educate providers.

A Delaware First Health spokesman said in a statement that the organization "has worked with DMMA as well as our members, providers, community partners and other MCOs to communicate these changes."

The organization − which is owned by the insurance company Centene, the largest private managed-care provider for Medicaid − said it will "honor" all prior approved procedures, services and benefits authorized by a previous MCO for 120 days starting from Jan. 1.

Delaware First Health did not respond to questions about how many people have unenrolled, what it is doing to help those who have been denied care and how it informed providers of these new changes.

Giffear, who is in the midst of a divorce and struggles with her mental health, said her therapist, psychiatrist and other doctors told her they could no longer see her due to Delaware First Health. She too has switched back to AmeriHealth.

Due to the change, she said she won't be able to see her doctors until March.

The situation has left her unable to refill one of her necessary prescriptions from her psychiatrist, as well as kept her away from her therapist, who she has been seeing for six months. Giffear said she always feels like she has an "agenda" on what she needs to do to make herself feel better after her therapy sessions.

But now, Giffear said she feels isolated.

"It put me backwards, let's put it that way," she said. "It puts me at least six or seven steps backwards."

Mermigos, the acting Medicaid director, said this therapist should have continued to provide Giffear services. If other Delaware First Health recipients are denied care, Mermigos said they need to tell their doctor that is not correct.

"They need to let their provider know: 'Yes, you can continue my service,'" he said, adding that they could also call the state's Health Benefit Manager and switch providers.

Lawyers from Delaware Community Legal Aid Society, who are helping Giffear and others in her situation, called the number for the Health Benefits Manager two weeks ago.

As of late January, they hadn't received a call back.

Are you now on Delaware First Health?

If you have been enrolled in Delaware First Health and you would like to switch back to your previous managed care organization, you have until April 1.

You can contact the Health Benefit Manager at 800-996-9969. This hotline has faced a significant call volume in recent weeks.

If you want to make sure the Delaware Department of Health and Social Services has your most up-to-date info, you can call the Medicaid Change Report Center at 302-571-4900.

Delaware Medicaid recipients can also update their contact information at assist.dhss.delaware.gov.

The Delaware Community Legal Aid Society has also been helping Delawareans who have been denied care following their enrollment into Delaware First Health.

You can call them at 302-575-0660.

"This rollout was completely and utterly disastrous."

John McNeal

Director of the State Council for Persons with Disabilities