Judge: California Medicaid Backlog Violates Law

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Judge: California Medicaid Backlog Violates Law

Nina Liss-Schultz

Hundreds of thousands of Californians who applied for Medicaid have had their applications illegally delayed, and many have experienced “substantial and irreparable harm” as a result of living without health insurance, an Alameda County Superior Court judge ruled last week.

Hundreds of thousands of Californians who applied for Medicaid have had their applications illegally delayed, and many have experienced “substantial and irreparable harm” as a result of living without health insurance, an Alameda County Superior Court judge ruled last week.

Health-care access advocates in September filed a lawsuit against the California Department of Health Care Services (DHCS), alleging that the state’s backlog of applications for Medi-Cal, the state version of Medicaid, was in violation of the law and caused Californians to suffer by forcing them to forgo health-care coverage.

Twelve million Californians are enrolled in Medi-Cal, including some 2.7 million new enrollees following the program’s expansion in 2013.

California law requires the DHCS to review and respond to a Medi-Cal application within 45 days of its submission. But due to the deluge of applications following the expansion of Medicaid and the roll-out of Covered California, the state insurance exchange formed under the Affordable Care Act, the DHCS was unable to review and notify applicants of their status in time.

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Last spring, more than 900,000 applications had yet to go through the review process, leaving residents without coverage.

Some applicants waited as long as a year to hear back about whether they qualify, according to the lawsuit.

In some cases, like that of Robert Rivera, the effects of the delay were fatal. Rivera, whose experience is detailed in the suit, submitted his Medi-Cal application in early January 2014. The agency granted him Medi-Cal benefits half a year later, but Rivera, who suffered from a number of chronic health conditions, had died from a pulmonary embolism two months earlier.

Judge Evelio M. Grillo agreed with the advocates who filed the suit, writing in his decision that the DHCS delay caused “irreparable harm” to low-income Californians.

Grillo ordered the state to no longer delay Medi-Cal applications past the 45 days provided by law. Pointing out that, despite the state’s reduction of the backlog from 900,000 in May to some 44,150 in December, the state may still not be able to comply with the 45-day rule.

Grillo also said that the state should grant provisional benefits to applicants who are “likely eligible,” pending final approval from the state.

Provisional benefits would allow residents to get coverage for health-care services while their applications are pending.

Department officials have said that they have begun providing provisional benefits for “likely eligible” applicants who are stuck in the backlog, and will continue doing so based on the judge’s findings.

Judge Grillo also ordered the state to provide written notice to people whose applications are backlogged, outlining their right to request a hearing to prevent further delay of their eligibility determination.

“I am just thrilled that the people who need Medi-Cal will be able to get it in a timely manner,” said Robert Rivera’s mother, Frances Rivera, in a statement. “Hopefully somebody’s life will be saved because of this decision.”