Is California getting stricter on health plans participating in Medi-Cal, California’s insurance program for low-income residents?

A few weeks ago, state regulators implemented A sort of A record $55 million fine LA Care, the largest Medi-Cal managed care plan in California, threatened the health of enrollees by failing to ensure adequate care and allowing delays in treatment. Patient advocates hope the move marks tighter enforcement of other Medi-Cal insurers that suffer from many of the same shortcomings that regulators just fined LA Care.

The 25 managed care programs across the state are nearly 12 million Among the more than 14 million Californians enrolled in Medi-Cal, the state is regularly accused of failing to hold programs accountable for substandard care. Medi-Cal members are among the most vulnerable in the state: They may face language and cultural barriers and have disproportionately high rates of chronic disease.

The state Department of Health Care Services, which operates Medi-Cal, is drafting a new Managed Care ContractScheduled to go into effect in 2024, officials say it will improve care by keeping participating health plans to a higher standard. The state hopes to close health disparities and improve health outcomes through increased oversight and enforcement.

“They’re trying to do more, which is really positive,” said Abbi Coursolle, a senior attorney at the law firm. National Health Law Program in Los Angeles. “Obviously, they still have a lot to do.”

DHCS and the state Department of Managed Care, which administers Medi-Cal managed care plans, launched a coordinated investigation into LA health care, based in part on 2020 Los Angeles Times report This highlights long-term care delays, sometimes fatal, at facilities operated by the Los Angeles County Department of Health Services. The agency operates the county’s public safety net system and contracts with LA Care to provide care to hundreds of thousands of health plan members. State regulators also relied on information LA Care reported to them in the investigation.

Their reliance on these resources raises questions about the effectiveness of their own oversight and audits, Coursolle said.

On March 4, the managed care unit fined LA Care $35 million — more than triple the previous maximum fine. The Department of Health Care Services collected $20 million, nearly eight times the amount previously recorded.

The state cited more than 100,000 violations, including slow responses to patient complaints and appeals, delayed or denied authorization of medically necessary care, and failure to ensure county health services compliance with patient care regulations. The California Department of Public Health, which oversees hospitals and other medical facilities, did not respond to questions about whether it was investigating any medical facilities in the county.

In announcing the fine, the head of the state agency said: “LA Care’s violations are serious enough to cause harm to its members and require immediate action.” The health plan has 2.4 million Medi-Cal participants.

“Recent enforcement actions against LA Care demonstrate that DHCS intends to exercise our authority to protect our Medi-Cal enrollees,” department spokesman Anthony Cava told me in an email.

LA Care CEO John Baackes said the program did not dispute the findings. “We’re arguing over the amount of the fine, which we don’t think is justified,” Bucks said. Disputes can take months or even years to resolve.

In a statement released after the fine was announced, LA Care pointed to Medi-Cal’s notoriously low payments to providers and said the fine “creates another financial hurdle for public health programs that are a key part of the health care safety net. “.

Although LA Care has generated multi-million-dollar profits in recent years, it reported a Loss of $132 million in fiscal 2020. But the program can withstand fines.At the end of last year, its net tangible assets (a key measure of solvency) were seven times Up to the minimum required by law.

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The violations described by the regulator are all too familiar to Culver City resident Theresa Grant, who I wrote about late last year. trying to find relief Because of severe pain in her ribs. She said the breaches were “horrific” and “I think it’s true.”

But she believes a great deal of the blame should be on specialists who are unable or unwilling to help her. “You know how long I’ve been dealing with my problems,” she told me. “It’s been over a year now and haven’t done any damn thing.”

Despite the hefty fines imposed on LA Care, consumer advocates and some state lawmakers argue that California needs to be empowered to impose larger fines.

A bill sponsored by consumer advocacy groups health visit would increase the fines many state health plan regulators can impose by at least tenfold. Supporters say the legislation, SB 858is required because the amount the department can legally charge health plans has not increased in some cases since 1975.

“We want to make sure that insurers don’t see these fines as mere costs of doing business,” said state Sen. Scott Weiner (D-San Francisco), the bill’s author. “By raising them, they become less of a business cost and more of an actual motivator to comply with the law.”

The fines imposed on LA Care are outliers because of their size, partly determined by the number of violations. “For every fine like this, there are a lot of fines that are much lower,” Wiener said. “I don’t want to rely on a case to say, ‘Oh, no problem, because they got a huge fine.'”

Another big factor that keeps health plans in limbo is consumer complaints, which have helped get the attention of regulators and the plans themselves, Wiener said.

but a last year’s report Research by KFF shows that consumer appeals to refusal of care are extremely rare.

If you have a problem with your health plan, or want to appeal a delay or denial of coverage, it is best to contact the Department of Managed Health Care (888-466-2219 or HealthHelp.ca.gov).

The state also has an ombudsman for Medi-Cal managed care (888-452-8609 or [email protected]).

You can also try the Healthy Consumers Coalition (888-804-3536 or www.healthconsumer.org), which helps people develop public and private health plans. It offers free advice, provides legal services, and can help you get documents to appeal.

Both regulators and health plans often say they work on behalf of patients. So if you’re not getting the care you need, stand up and participate in the solution.

This story is made by KHNrelease California Healthlineeditorial independent service California Healthcare Foundation.

Kaiser Health News is a national health policy news service. It is an independent editorial project of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.