Computer problems and human error still cause headaches for insurance

As California expands health coverage under the Affordable Care Act, a large number of people have mistakenly bounced in the state market for Medicare, the state’s Medicaid program, and Medi-Cal, the state’s Medicaid program for low-income residents.

Small changes in income can change a person’s qualifications, but when bad data is typed on a computer system shared by two programs – or the correct information is deleted – the registrants can get big headaches.

Chronic tensions within the state, which oversees Medi-Cal, and county officials work tirelessly to determine who qualifies and who is qualified. And, sometimes, people applying for coverage inadvertently answer questions in a way that qualifiers change them from one program to another.

Legal aid attorneys, patient advocates and insurance agents say computer problems are not as common today as they were a few years after the introduction of ACA coverage in California in 2013. The exchange was new and millions of people were eligible for Medi-Cal in a new way State officials have dealt with computer errors and other problems as they appear.

But it is not possible to eliminate all human and computer errors.

Just ask Andrea Weltman, who received a notice in December that her subsidized covered California health plan was being discontinued. The letter instructed the 57-year-old Oakland resident to apply for Medi-Cal. When he calls the program, he learns that Medi-Cal coverage for his 25-year-old son Marilyn is also being discontinued. He had to re-apply.

Veltman, who owns a landscaping business, was confused. He made some calls and found out that a Medi-Cal qualification officer had logged in to both of their accounts and somehow merged the two accounts. All of her husband’s information has been deleted, her business has been deleted, her son’s income has been nullified and some of her income has been attributed to her.

No one contacted him to verify the changes.

Weltman does not know if the human or computer error was responsible. She suspects a review of the accounts began when her son applied for food aid and listed her as an acquaintance.

“Even if something triggers them to see it, they need to verify that it is accurate information – and that it was incredibly wrong,” he says. “And that’s not right. Why don’t they ask me?”

Veltman’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. He learned last week that his covered California coverage has been restored this month, but he still doesn’t know if he will be covered in advance for treatment in May.

Kevin Knauss, an insurance agent in Granite Bay, says 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 information disruptions in computers that affect their competence,” he said.

Perhaps the most serious aspect of Weltman’s case is that his son’s Medi-Cal termination violated a rule that prevented people from being excluded from Medicaid during the Federal Public Health Emergency declared at the start of the Cavid-19 epidemic.

“It simply came to our notice then. It’s against the law during an epidemic, “said Jack Daly, an attorney for the San Diego Legal Aid Society. “We urge people to step back immediately, and they will be reinstated immediately.”

The rules, which typically suspend annual reviews of qualifiers, have enabled many Californians to maintain their Medi-Cal coverage during epidemics. 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 is almost certain to be extended.

Medi-Cal took several months to effectively implement the procedures required to comply with the rules. For several months in 2020, 131,000 enrolled people were mistakenly excluded from coverage but eventually reinstated, according to the State Department of Health Care Services, which operates Medi-Cal. And such incidents have slowed sharply since then.

“Their problems have diminished over the last year or so,” said Skyler Rosellini, a senior attorney at the National Health Law Program. “But they still pop up.”

In the unlikely event this kind of mistake happens to you, a quick call to your county qualification office can resolve things. 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 if your patience is running low, you can get advice and legal help from the Health Consumer Alliance (888-804-3536). Or www.healthconsumer.org). Insurance agents can also bring a lot of expertise to help you solve your problem. You can find agents through the California Agent and Health Insurance Professionals Group (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 fill out a request online).

You can also ask for a fair hearing to settle a dispute over eligibility for a subsidized covered California health plan or to challenge the amount of tax credit you have been given to help pay your premium.

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

Finally, Weltman has some practical tips: Keep track of your submitted income or take a screenshot of it – otherwise, if it is deleted, you’ll need to recalculate everything.

“Also, just keep calling,” she says, “because they sometimes tell you, ‘We’re going to call you again,’ 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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