Children left behind?

What state’s transition from Healthy Families to Medi-Cal means for kids

More on Medi-Cal:
Log onto (the home page for the California Department of Health Care Services) for specifics about changes to the state’s Medicaid program.

At the start of the month, parents of several thousand local children found their families on a new health-insurance plan. The state of California, including Butte County, has blended its Healthy Families Program into Medi-Cal, beginning Nov. 1.

The transition may be most troublesome to families with children requiring specialty care, like those with autism spectrum disorder. At the beginning of the year, about 400 of California’s autistic children lost coverage for applied behavior-analysis (ABA) therapy after the state began the switch to Medi-Cal on Jan. 1, despite a Department of Health Care Services letter that assured families “Your child’s coverage will not be interrupted.”

Prior to the transition, Healthy Families and Medi-Cal were parallel plans offering coverage to children of low-income families. Healthy Families enrollees had parents whose earnings put them above the threshold for Medi-Cal. A primary difference between the two is Healthy Families, administered by Anthem Blue Cross, has reimbursed private physicians at a higher rate than Medi-Cal, so when doctors’ offices put limits on the number of Medi-Cal patients they’d accept—as has become increasingly common—Healthy Families patients didn’t encounter that same barrier.

With the expansion of Medi-Cal under the federal Affordable Care Act, the state decided to discontinue Healthy Families and transfer the 875,000 children in Healthy Families to Medi-Cal, which, moving forward, will be administered by two companies: Anthem Blue Cross and California Health & Wellness, a subsidiary of the Missouri-based Centene Corporation. State officials designed the transition in phases; Phase 4b, the final phase, comprised rural counties including Butte.

The child-advocacy group Children Now has been monitoring the process.

“We know from experience that these changes tend to have disruptions despite everybody’s best intentions,” said Ben Rubin, an associate for health policy at Children Now. “There may be changes to the providers that kids and families are going to see, for example, so it’s been a critical part of our work to make sure the state is properly informing families of the changes so they know who to call and how to prevent any problems due to interruption of care.”

Rubin said most Healthy Families patients should be able to stay with their primary-care provider (PCP) and dentist if their parents choose the Anthem Blue Cross option for Medi-Cal. An adequacy assessment by the California Department of Health Care Services found 97 percent of the PCPs in the Healthy Families network are in the Medi-Cal network as well. The state did not release statistics on California Health & Wellness’ plan.

Where the big problem lies is in specialty care. Only 34 percent of the Butte County specialists who’ve accepted Healthy Families also accept Medi-Cal. So, families of children with intensive health needs may find themselves switching doctors or struggling to find a new one. Rubin acknowledged that so far through the transition, parents of children with autism spectrum disorders have tended to experience the biggest challenges.

“That’s a long-standing problem with Medi-Cal,” said Dr. Craig Corp, a pediatrician in Chico. “There are many specialties that we need to refer out of the area for services because no one will see them here. It’s frustrating.”

The Medi-Cal expansion means more people will join the system, even beyond the 875,000 Healthy Families patients (2,070 in Butte County). Some of those children will have trouble even finding PCPs. Corp pointed out that the Medi-Cal network includes physicians whose only Medi-Cal patients are those already established in the practice, and perhaps the siblings of those children. Families new to Medi-Cal may need to seek out clinics—such as Northern Valley Indian Health’s Children’s Health Center, the Ampla Health Center, Feather River Hospital or Oroville Hospital—if they can’t find a private pediatrician.

In terms of Medicaid (Medi-Cal in California) reimbursement levels to health-care providers, California is 49th out of the 50 states, Corp said. “There are many other states where Medicaid reimburses at a similar rate to, say, a Blue Cross or Blue Shield, and people are happy to take it.”

Corp explained that historically, about 80 percent of California physicians either haven’t accepted or have limited Medi-Cal patients because of the low reimbursement rate.

“Basically [Medi-Cal will] pay a lot more to the clinics—the rural health clinics, the federally qualified health clinics—than we get paid,” he said. “That’s essentially where they want the Medi-Cal patients to go.”

Participants in the Healthy Families program should have received advance notice of the transition to Medi-Cal, but there remain families who have not been notified. To them, Children Now stresses some key points:

• Medi-Cal coverage includes all the benefits of Healthy Families coverage.

• Children have a right to continuous care through the transition. In other words, even if they need to switch doctors or dentists, children in Healthy Families should have no gap in coverage.

• Children have a right to coverage for any medically necessary covered services, including specialty services, even if the services are not in the health-plan network.

• Premiums will not increase, and families with incomes below 150 percent of the federal poverty line will no longer be charged premiums once they move to Medi-Cal.

“Overall in the transition there haven’t been wide-scale problems,” Rubin said, “but that’s not to say there haven’t been problems.”

Children Now says a family’s new health plan should direct them to the correct service provider. Those having trouble accessing care or coverage can contact the Medi-Cal ombudsman at (888) 452-8609.