Computer failures and human error in insurance coverage continue

Since California has expanded health coverage under the Affordable Care Act (ACA), a large number of people mistakenly enrolled in covered California, state programs for those buying their own insurance, or Medi-Cal, the state’s Medicaid plan for low-income residents.

It is true that small changes in income can lead to qualification changes, but if incorrect information is entered into a computer system shared by two programs, or correct information is deleted, it can be a major headache for members.

The long-running tension between Medi-Cal’s supervising state and county officials who do the necessary work to determine eligibility and list those who qualify does not help. And sometimes, those who apply for coverage unknowingly answer questions in a way that causes officials to switch from one program to another.

Legal aid attorneys, patient advocates and insurance agents say computer crashes are not as common today as they were in 2013, years after California introduced extended ACA coverage. The insurance market was brand new then, and millions of people became eligible for Medi. Cal State officials corrected computer errors and other problems as they emerged.

But it is not possible to eliminate all the faults of human and computer.

If not, ask Andrea Weltman, who received a notice last December that her covered California subsidized health plan was discontinued. The letter instructed the 57-year-old Oakland resident to apply for Medi-Cal. When he called the program, he learned that Medi-Cal coverage for his 25-year-old son, Marilyn, had also been discontinued. I have to apply again.

Weltman, owner of a landscaping business, was confused. He made a few calls and discovered that a Medi-Cal official had logged into both accounts and somehow merged the two. All information about her husband was deleted; They shut down his business, reduced his son’s income to zero, and charged him a portion of the income.

No one contacted him to verify the information.

Weltman does not know if human or computer error was to blame. She suspects they reviewed the accounts after her son applied for food aid and listed her as one of their acquaintances.

“Even if some ask them to look at it, they need to verify that it is accurate information; It was completely wrong, “he said. “And that’s not right. Why don’t they ask me?”

Weltman’s son did not receive his Medi-Cal coverage until mid-May. His covered California coverage was quickly restored in late December, but then the same thing happened in late April.

A few days ago, he learned that his covered California coverage would be restored June 1, but he still doesn’t know if he will have backdated coverage for his May treatment.

Kevin Nows, an insurance agent in Granite Bay, said he has heard similar complaints in recent months from residents of Alameda, Los Angeles, Orange, San Diego and Santa Barbara counties.

“These are calls about incorrect information on the computer that affects your eligibility,” he said.

Perhaps the most tragic aspect of Weltman’s case is that his son’s Medi-Cal termination violated a rule that prevented the Federal Public Health Emergency from naming people from Medicaid at the time the COVID-19 epidemic was announced.

“It simply came to our notice then. It goes against the rules during an epidemic, “said Jack Daly, an attorney for the San Diego Legal Aid Society. “We tell people to push and they will reinstate immediately.”

The mandate, which typically suspends annual reviews to determine members’ eligibility, has allowed many Californians to keep their Medi-Cal coverage during the epidemic. These reviews will resume once the public health emergency is over and millions of people could lose Medi-Cal coverage.

The public health emergency is due to end on July 15, but it will almost certainly be extended.

It took several months to implement the procedures required to comply with the Medi-Cal rule. Over the months leading up to 2020, 131,000 were mistakenly excluded from coverage, although they were eventually reinstated, according to the state Department of Healthcare Services, which manages Medi-Cal. And those events have dropped dramatically since then.

“It must have been a minor issue last year or so,” said Roslerini, a senior attorney at the National Health Law Program. “But they can still happen.”

In the unlikely event you encounter this type of error, a quick call to your county qualification office can fix it. You can find a list of county offices on the Department of Health Care Services website (www.dhcs.ca.gov).

If that doesn’t work, or you run out of patience, you can get legal advice and help from the Health Consumer Alliance (888-804-3536 or www.healthconsumer.org). Insurance agents can also bring their skills to help solve problems. You can find agents for California agents and health insurance professionals (www.cahu.org/find-a-member).

If you are still not satisfied, you can request a “fair hearing” before an administrative law judge through the state Department of Social Services (call 855-795-0634 or complete an online request).

You can request a fair hearing to challenge the eligibility for a covered California subsidized health plan or to challenge the amount of tax credits paid to help pay your premium.

But before you do, call the program’s customer service line (800-300-1506) to try to resolve the issue. Covered California also has an ombudsman (888-726-0840 or [email protected]).

Veltman also has some simple tips: keep track of your submitted earnings or take a screenshot; Otherwise if it is deleted you will have to count everything again.

“Also, keep calling,” he said, “because sometimes they say, ‘We’ll call you,’ and it almost never happens.”

The story was produced by KHN, which publishes the California Healthline, an editorially independent service of the California Health Care Foundation.

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