This KHN story can be republished for free. (details)

California voters are showing strong early support for a ballot initiative that would expand the state’s authority to regulate health insurance rates.

Nearly 7 of every 10 respondents indicated that they would vote in favor of Proposition 45, while 16 percent would vote against it, according to an independent by the Field Research Corp. in San Francisco.

Proposition 45 would give California’s insurance commissioner the power to veto health insurance rate increases.

Health insurance rates in the state are currently overseen by the Department of Managed Health Care and the California Department of Insurance. Insurance companies are required to submit proposed rate increases for review each year by state regulators, who may declare rates unreasonable but cannot block them from going into effect.

“This is the missing piece of health reform,” says Carmen Balber, executive director of Consumer Watchdog in Santa Monica, the advocacy group that sponsored the initiative. “If every Californian is required to purchase health insurance and no one is overseeing what insurance companies can charge, the insurance industry will have a free pass to raise prices at will.”

Insurance Commissioner Dave Jones, too, strongly supports the proposition.

Since 2011, insurers have proceeded at least 14 times with rate hikes  deemed unreasonable by California regulators, according to the California Public Interest Research Group, a consumer advocacy group in Sacramento. Consumer Watchdog says that those rate increases have cost consumers more than $250 million.

Not everyone agrees that Proposition 45 will cut health insurance costs, however. Critics say that the initiative would do nothing to reduce underlying health care costs, but could add a costly bureaucracy to the state’s health insurance marketplace. Some also worry that the proposition could expose insurers to legal challenges on rate increases.

“It’s going to drive the costs up dramatically,” says Neil Crosby, a spokesperson for the California Association of Health Underwriters, a Sacramento-based group that represents the private health insurance industry. The campaign against Proposition 45 has received major financial backing from insurance providers such as the Kaiser Foundation Health Plan and Blue Shield of California. (Kaiser Health News is not affiliated with Kaiser Permanente or the Kaiser Foundation Health Plan.)

Peter Lee, executive director of Covered California, the state’s health care exchange, told legislators in July that the proposition could undermine the exchange’s ability to negotiate rates directly with health plans. For now, the exchange wields the bargaining power of 1.4 million people having signed up for insurance through Covered California since last fall.

An additional layer of rate review and any potential disputes with the insurance commissioner could keep some plans from being available in time for open enrollment, Lee said, and might even cause some health plans to withdraw from certain markets.

Insurance laws vary widely from state to state, but more than half of states already require some health insurance rate increases to be approved by the government before they can be implemented, according to data from the National Association of Insurance Commissioners.

The Affordable Care Act further expanded insurance rate oversight by requiring, for coverage beginning in 2011, that individual health plans spend at least 80 percent of premium costs on medical expenses. Many states, including California, have also received federal grants through the Affordable Care Act to hire actuaries to help government agencies review insurance rates more thoroughly.

Some states that require prior approval of rates have had to plan ahead to meet open enrollment timelines under the health law, says Sabrina Corlette, a senior research fellow at the Georgetown University Health Policy Institute in Washington, D.C. But in general, she says the extra reviews have not posed a problem. “We have not heard that plans just weren’t ready to be sold when open enrollment came around,” says Corlette.

The Field Poll was among the very first to survey state residents on Proposition 45 and a strong blitz by the insurance companies during the fall campaign season could affect public opinion. Insurers have donated millions of dollars to a campaign to defeat the measure.

Nonetheless, some observers say the proposition may not make a big difference in the short term.

Current market forces and the added restrictions from the health law seem to be helping to keep rate increases low in California, says Dylan Roby, a health policy professor at the University of California, Los Angeles. At the end of July, Covered California announced negotiated rate increases for 2015, averaging a modest 4.2 percent across the state.

The additional oversight could become more relevant in the future, says Roby, if health care spending begins to increase dramatically.

At the same time, Roby warns that without proper foresight, the proposition could leave certain markets vulnerable to coverage disruptions. For example, he said, in areas that are costlier to insure, and especially where competition among insurers is lower, Covered California may be forced to accept higher rate increases to keep an insurer’s plan in that jurisdiction. But if the insurance commissioner were to reject those negotiated rates, the health plan  could decide to pull out of that area altogether.

Close communication between all parties early on in rate negotiations will be key to maintaining statewide access to health insurance, if Proposition 45 passes in November, says Roby.

“Balancing the needs of the insurance commissioner and Covered California could be tricky,” he says.

The Field Poll, which looked at a variety of health issues including Medicaid and the Covered California exchange,  was conducted through telephone interviews of more than 1,500 state residents from June 26 through July 19. It has a margin of error of plus or minus 2.6 percentage points.

helps support KHN coverage of California.

This <a target="_blank" href="/insurance/california-survey-health-insurance-rates-and-prop-45/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

For months, the state has labored under the largest such pile-up in the country, with 900,000 pending cases reported in May—the combined result of unexpectedly high application numbers and bug-ridden computer systems.

In a  on Monday, the California Department of Health Care Services said that it had reduced its application backlog to 600,000 by the start of this month. State officials also outlined a plan for technology fixes and administrative workarounds that they project will nearly halve that figure by the end of August—with most of those applications being processed within the allowed 45-day window. The letter was made public Tuesday.

If successful, the plan would provide much-needed relief for many Californians. Some have put off treatment for months while awaiting their Medi-Cal cards. (Medi-Cal is the state’s version of the Medicaid program for the poor and disabled.)

But many health advocates remain skeptical. “I don’t think this is necessarily going to be resolved within six weeks,” says Shana Charles, a health policy expert at the University of California, Los Angeles.

California was one of several states to receive  on June 27, which cited the agency’s concerns about enrollment problems. Alaska, California, Kansas, Michigan, Missouri and Tennessee were each given 10 business days to submit plans for dealing with issues ranging from updating income eligibility criteria to communication problems between state and federal computer systems.

“I think the common theme is technology, and a lack of readiness,” says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities in Washington, DC.

Of the six, California and Michigan are the only states that had opted to expand Medicaid eligibility to a wider range of low-income adults under the Affordable Care Act. But all 50 states were required under the law to update Medicaid eligibility criteria—which once differed from state to state—to a single unified standard.

Changing computer systems to comply with this new standard has proved more difficult and time-consuming for some states than others—with many health departments resorting to manual processing as a short-term fix. Tennessee received particular criticism from the federal agency for repeated delays in developing its new computer system, and for shunting the bulk of its Medicaid applications to the federal portal in the meantime. The state has said that it expects to launch its new system by mid-September, nine months later than originally planned, according to the Centers for Medicare & Medicaid Services.

According to the letters, state computer systems in Alaska, Kansas, and Michigan have had problems taking in applications for Medicaid submitted through the federal health insurance website, healthcare.gov. Michigan, for example, is awaiting 85,000 applications that have yet to be transferred to the state from the federal portal. All three of these states submitted plans to resolve this issue or begin processing applications from federal channels within the month.

California has set up its own health insurance website, but the state computer system has encountered repeated problems in communicating with county systems for verifying eligibility. In its letter to the federal agency, the health department said it planned to keep upgrading the interface between the two systems, and to continue its efforts to process some groups of applications in bulk. Other workarounds include allowing applicants themselves to attest to their state residency while automated verification methods are being developed.

The state also reports that about 10 percent of its applications are duplicates of applications already in the system—a problem that has slowed processing and hindered the health department’s attempts to quantify the scope of its backlog. Health officials say they plan to add messages on the health insurance website to warn consumers against adding to the pile-up.

All of these fixes add up to a large, time-consuming task, which some experts believe will exceed the six-week timeframe that California has proposed.

“The technical changes have taken longer at every step of the way than anticipated,” says Jen Flory, a senior attorney at the Western Center on Law and Poverty in Sacramento. ” We have been hoping since February that the glitches would be resolved within a matter of weeks, and that hasn’t happened.”

While California continues to fight its backlog, the Centers for Medicare & Medicaid Services has turned its attention to other states’ bottlenecks. On July 9, the agency notified seven states—Arkansas, Georgia, Illinois, Indiana, North Carolina, Virginia and Wyoming—that it would be conducting reviews of ‘substantial backlog’ issues affecting those states. Some observers say that the recent spate of letters from the agency could signal the beginning of increased scrutiny on long Medicaid lines and application processing times across the country.

“They’ve been patient in the sense of not taking action right away,” says Solomon. “We’re seeing that it is time now for the states to step up.”

This <a target="_blank" href="/medicaid/medi-cal-application-backlog-california/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This KHN story also ran in . It can be republished for free. (details)

A massive backlog of Medi-Cal applications is well into its third month, and California officials have provided little information about how and when the largest such bottleneck in the nation might be cleared.

The California Department of Health Care Services in Sacramento first reported 800,000 pending applications in April. By May, that number had grown by 100,000 and has not budged much since.  As the state works through older applications, new ones continue each day to enter the system, which has been plagued by computer glitches and inefficient procedures for verifying applicants’ personal information.

There are no estimates of processing times or how long delays will persist, though a state official said last month that new applications in May appeared to have slowed.

“All the resources are just devoted to getting people moving forward,” said Norman Williams, a department spokesman.

Not only has application processing been delayed, the state has fallen behind in sending final notifications to enrollees, officials confirmed. Meanwhile, many people are showing up at community clinics and costly emergency rooms as they have in the past. Others are putting off care.

Although Medi-Cal coverage is retroactive from the time eligible patients apply, some don’t trust they will be covered until they have a card in hand.

“I’m afraid to go to the hospital,” said Adolfo Rodriguez, 35, of East Palo Alto. “I can’t afford it.”

Rodriguez’s Medi-Cal application has been pending since March. In the meantime, he said, he can’t do his job as a truck driver – he needs to see a specialist about severe muscle and joint pain.

Part of the problem is high demand. In California, as in many of the 26 states that opted to expand Medicaid eligibility under the Affordable Care Act, people turned out in much higher numbers than projected. The state health department said it now expects 2.2 million people to enroll in Medi-Cal this month —300,000 more than estimated last fall.

Since last fall, 40 percent more people have signed up for Medi-Cal than the number who enrolled in private insurance through Covered California, the state’s health insurance exchange. Roughly 1.4 million of those applicants were newly eligible for Medi-Cal, which was expanded to serve people up to 138 percent of the federal poverty level. About 600,000 more were previously eligible for coverage but had not enrolled. Experts say the massive outreach campaigns across the country helped alert many of these people to their eligibility.

Unanswered Questions

State health officials said about half of the 900,000 pending applications have been filed within the past 45 days—the maximum processing period typically allowed by law. Little is known about the other half, and why they have exceeded this time window.

“It’s difficult to determine exactly who is in that 900,000 and for what reason,” said Williams, the health department spokesman.

Although California experienced an initial swell of applications in December 2013, a second, enormous wave landed in March, as people scrambled to meet the deadline for obtaining insurance coverage.

“We did not anticipate the surge in applications to this extent,” said Anastasia Dodson, associate director of policy at the California Department of Health Care Services.

The state has refused to release the number of applications that were backlogged before April. “The numbers for previous months probably wouldn’t be accurate for readers,” said Dodson. Among other reasons, she said that the health department did not realize how many duplicated applications were stuck in the mix, as frustrated users tried repeatedly to sign up for Medi-Cal. “We had people who applied 30 times,” Dodson said.

The department has since identified and removed duplicate applications to arrive at the figures that have been reported since April.

Though details remain sketchy, one problem was delayed development of an interface that would connect the state’s new system with old county-based social services computer systems for verifying Medi-Cal eligibility. Some people were able to sign up smoothly by applying in-person at county health departments. But many applications submitted through the state website stalled.

Some applications have been delayed by missing or inaccurate information. Others have been slowed by outdated procedures for verifying residency—only recently replaced by an automated verification system.

Critics say that launching the Covered California insurance exchange was made a higher priority than improving the online enrollment process for Medi-Cal patients, despite their great numbers.

“In a very short period of time, there was a lot of work to do, and I think the folks that make the priorities decided that the particular piece for Medi-Cal recipients could wait,” said Frank Mecca, executive director of the County Welfare Directors Association of California.

Uncertainty For Providers And Patients

Although open enrollment for private insurance plans closed in April, Medi-Cal enrollment remains open year-round, leaving little breathing room for health officials.

The holdup in Medi-Cal approvals has led to financial uncertainty for many of California’s community health clinics, which depend on Medi-Cal payments to supplement the reduced fees or fee waivers they accept from low-income, uninsured patients. A number of centers have recently expanded facilities, staff and services in anticipation of a wave of Medi-Cal patients and the extra cash they would bring.

“We basically don’t know if we’re going to be receiving payment for the services we’re providing,” said Carmela Castellano-Garcia, chief executive of the California Primary Care Association, which represents more than 1,000 community clinics and health centers. Private providers are even more wary.

“A typical private practice might say, ‘You’re uninsured,’ and be unwilling to participate in that bureaucracy of claims that need to be paid retroactively,” said Dylan Roby, a health policy professor at the University of California, Los Angeles. Patients, too, have been left in limbo.

“They’re afraid they may not be approved and that they’ll be stuck with this huge bill,” said Irais Bazan, an enrollment and eligibility manager at Ravenswood Family Health Center in East Palo Alto.

Rodriguez said he that he did not know about his retroactive payment options when he visited a county hospital in San Mateo two months ago for his muscle and joint pains. He borrowed money from his brother to pay off the $1,400 bill—much larger than he had expected.

He could not afford the pain medications that the doctor prescribed. He still does not have a diagnosis and said he will not try again until his Medi-Cal card arrives.

Thomas Kurthy of Los Angeles is waiting for his Medi-Cal card so that he can get a physical and a colonoscopy. His father was recently treated for cancer, and Kurthy said he wants to stay on top of his health. 

His last doctor’s visit was in 2012. Since January, the 51-year-old garden designer has amassed a large folder of notes as he has tried to follow up with local health advocates, navigators, county health workers, and others who at various times have handled his Medi-Cal application.

“I’ve been bounced around from office to office, person to person,” said Kurthy. “I think if I didn’t stay on top of this, I would never hear from anybody.”

Last month, a county health worker told Kurthy that his application had a good chance of being decided within the next 30 to 45 days.

Helen.H.Shen@gmail.com

This <a target="_blank" href="/medicaid/mountainous-backlog-stalls-medical-expansion-in-california/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This KHN story can be republished for free. (details)

California voters are showing strong early support for a ballot initiative that would expand the state’s authority to regulate health insurance rates.

Nearly 7 of every 10 respondents indicated that they would vote in favor of Proposition 45, while 16 percent would vote against it, according to an independent by the Field Research Corp. in San Francisco.

Proposition 45 would give California’s insurance commissioner the power to veto health insurance rate increases.

Health insurance rates in the state are currently overseen by the Department of Managed Health Care and the California Department of Insurance. Insurance companies are required to submit proposed rate increases for review each year by state regulators, who may declare rates unreasonable but cannot block them from going into effect.

“This is the missing piece of health reform,” says Carmen Balber, executive director of Consumer Watchdog in Santa Monica, the advocacy group that sponsored the initiative. “If every Californian is required to purchase health insurance and no one is overseeing what insurance companies can charge, the insurance industry will have a free pass to raise prices at will.”

Insurance Commissioner Dave Jones, too, strongly supports the proposition.

Since 2011, insurers have proceeded at least 14 times with rate hikes  deemed unreasonable by California regulators, according to the California Public Interest Research Group, a consumer advocacy group in Sacramento. Consumer Watchdog says that those rate increases have cost consumers more than $250 million.

Not everyone agrees that Proposition 45 will cut health insurance costs, however. Critics say that the initiative would do nothing to reduce underlying health care costs, but could add a costly bureaucracy to the state’s health insurance marketplace. Some also worry that the proposition could expose insurers to legal challenges on rate increases.

“It’s going to drive the costs up dramatically,” says Neil Crosby, a spokesperson for the California Association of Health Underwriters, a Sacramento-based group that represents the private health insurance industry. The campaign against Proposition 45 has received major financial backing from insurance providers such as the Kaiser Foundation Health Plan and Blue Shield of California. (Kaiser Health News is not affiliated with Kaiser Permanente or the Kaiser Foundation Health Plan.)

Peter Lee, executive director of Covered California, the state’s health care exchange, told legislators in July that the proposition could undermine the exchange’s ability to negotiate rates directly with health plans. For now, the exchange wields the bargaining power of 1.4 million people having signed up for insurance through Covered California since last fall.

An additional layer of rate review and any potential disputes with the insurance commissioner could keep some plans from being available in time for open enrollment, Lee said, and might even cause some health plans to withdraw from certain markets.

Insurance laws vary widely from state to state, but more than half of states already require some health insurance rate increases to be approved by the government before they can be implemented, according to data from the National Association of Insurance Commissioners.

The Affordable Care Act further expanded insurance rate oversight by requiring, for coverage beginning in 2011, that individual health plans spend at least 80 percent of premium costs on medical expenses. Many states, including California, have also received federal grants through the Affordable Care Act to hire actuaries to help government agencies review insurance rates more thoroughly.

Some states that require prior approval of rates have had to plan ahead to meet open enrollment timelines under the health law, says Sabrina Corlette, a senior research fellow at the Georgetown University Health Policy Institute in Washington, D.C. But in general, she says the extra reviews have not posed a problem. “We have not heard that plans just weren’t ready to be sold when open enrollment came around,” says Corlette.

The Field Poll was among the very first to survey state residents on Proposition 45 and a strong blitz by the insurance companies during the fall campaign season could affect public opinion. Insurers have donated millions of dollars to a campaign to defeat the measure.

Nonetheless, some observers say the proposition may not make a big difference in the short term.

Current market forces and the added restrictions from the health law seem to be helping to keep rate increases low in California, says Dylan Roby, a health policy professor at the University of California, Los Angeles. At the end of July, Covered California announced negotiated rate increases for 2015, averaging a modest 4.2 percent across the state.

The additional oversight could become more relevant in the future, says Roby, if health care spending begins to increase dramatically.

At the same time, Roby warns that without proper foresight, the proposition could leave certain markets vulnerable to coverage disruptions. For example, he said, in areas that are costlier to insure, and especially where competition among insurers is lower, Covered California may be forced to accept higher rate increases to keep an insurer’s plan in that jurisdiction. But if the insurance commissioner were to reject those negotiated rates, the health plan  could decide to pull out of that area altogether.

Close communication between all parties early on in rate negotiations will be key to maintaining statewide access to health insurance, if Proposition 45 passes in November, says Roby.

“Balancing the needs of the insurance commissioner and Covered California could be tricky,” he says.

The Field Poll, which looked at a variety of health issues including Medicaid and the Covered California exchange,  was conducted through telephone interviews of more than 1,500 state residents from June 26 through July 19. It has a margin of error of plus or minus 2.6 percentage points.

helps support KHN coverage of California.

This <a target="_blank" href="/insurance/california-survey-health-insurance-rates-and-prop-45/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

For months, the state has labored under the largest such pile-up in the country, with 900,000 pending cases reported in May—the combined result of unexpectedly high application numbers and bug-ridden computer systems.

In a  on Monday, the California Department of Health Care Services said that it had reduced its application backlog to 600,000 by the start of this month. State officials also outlined a plan for technology fixes and administrative workarounds that they project will nearly halve that figure by the end of August—with most of those applications being processed within the allowed 45-day window. The letter was made public Tuesday.

If successful, the plan would provide much-needed relief for many Californians. Some have put off treatment for months while awaiting their Medi-Cal cards. (Medi-Cal is the state’s version of the Medicaid program for the poor and disabled.)

But many health advocates remain skeptical. “I don’t think this is necessarily going to be resolved within six weeks,” says Shana Charles, a health policy expert at the University of California, Los Angeles.

California was one of several states to receive  on June 27, which cited the agency’s concerns about enrollment problems. Alaska, California, Kansas, Michigan, Missouri and Tennessee were each given 10 business days to submit plans for dealing with issues ranging from updating income eligibility criteria to communication problems between state and federal computer systems.

“I think the common theme is technology, and a lack of readiness,” says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities in Washington, DC.

Of the six, California and Michigan are the only states that had opted to expand Medicaid eligibility to a wider range of low-income adults under the Affordable Care Act. But all 50 states were required under the law to update Medicaid eligibility criteria—which once differed from state to state—to a single unified standard.

Changing computer systems to comply with this new standard has proved more difficult and time-consuming for some states than others—with many health departments resorting to manual processing as a short-term fix. Tennessee received particular criticism from the federal agency for repeated delays in developing its new computer system, and for shunting the bulk of its Medicaid applications to the federal portal in the meantime. The state has said that it expects to launch its new system by mid-September, nine months later than originally planned, according to the Centers for Medicare & Medicaid Services.

According to the letters, state computer systems in Alaska, Kansas, and Michigan have had problems taking in applications for Medicaid submitted through the federal health insurance website, healthcare.gov. Michigan, for example, is awaiting 85,000 applications that have yet to be transferred to the state from the federal portal. All three of these states submitted plans to resolve this issue or begin processing applications from federal channels within the month.

California has set up its own health insurance website, but the state computer system has encountered repeated problems in communicating with county systems for verifying eligibility. In its letter to the federal agency, the health department said it planned to keep upgrading the interface between the two systems, and to continue its efforts to process some groups of applications in bulk. Other workarounds include allowing applicants themselves to attest to their state residency while automated verification methods are being developed.

The state also reports that about 10 percent of its applications are duplicates of applications already in the system—a problem that has slowed processing and hindered the health department’s attempts to quantify the scope of its backlog. Health officials say they plan to add messages on the health insurance website to warn consumers against adding to the pile-up.

All of these fixes add up to a large, time-consuming task, which some experts believe will exceed the six-week timeframe that California has proposed.

“The technical changes have taken longer at every step of the way than anticipated,” says Jen Flory, a senior attorney at the Western Center on Law and Poverty in Sacramento. ” We have been hoping since February that the glitches would be resolved within a matter of weeks, and that hasn’t happened.”

While California continues to fight its backlog, the Centers for Medicare & Medicaid Services has turned its attention to other states’ bottlenecks. On July 9, the agency notified seven states—Arkansas, Georgia, Illinois, Indiana, North Carolina, Virginia and Wyoming—that it would be conducting reviews of ‘substantial backlog’ issues affecting those states. Some observers say that the recent spate of letters from the agency could signal the beginning of increased scrutiny on long Medicaid lines and application processing times across the country.

“They’ve been patient in the sense of not taking action right away,” says Solomon. “We’re seeing that it is time now for the states to step up.”

This <a target="_blank" href="/medicaid/medi-cal-application-backlog-california/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This KHN story also ran in . It can be republished for free. (details)

A massive backlog of Medi-Cal applications is well into its third month, and California officials have provided little information about how and when the largest such bottleneck in the nation might be cleared.

The California Department of Health Care Services in Sacramento first reported 800,000 pending applications in April. By May, that number had grown by 100,000 and has not budged much since.  As the state works through older applications, new ones continue each day to enter the system, which has been plagued by computer glitches and inefficient procedures for verifying applicants’ personal information.

There are no estimates of processing times or how long delays will persist, though a state official said last month that new applications in May appeared to have slowed.

“All the resources are just devoted to getting people moving forward,” said Norman Williams, a department spokesman.

Not only has application processing been delayed, the state has fallen behind in sending final notifications to enrollees, officials confirmed. Meanwhile, many people are showing up at community clinics and costly emergency rooms as they have in the past. Others are putting off care.

Although Medi-Cal coverage is retroactive from the time eligible patients apply, some don’t trust they will be covered until they have a card in hand.

“I’m afraid to go to the hospital,” said Adolfo Rodriguez, 35, of East Palo Alto. “I can’t afford it.”

Rodriguez’s Medi-Cal application has been pending since March. In the meantime, he said, he can’t do his job as a truck driver – he needs to see a specialist about severe muscle and joint pain.

Part of the problem is high demand. In California, as in many of the 26 states that opted to expand Medicaid eligibility under the Affordable Care Act, people turned out in much higher numbers than projected. The state health department said it now expects 2.2 million people to enroll in Medi-Cal this month —300,000 more than estimated last fall.

Since last fall, 40 percent more people have signed up for Medi-Cal than the number who enrolled in private insurance through Covered California, the state’s health insurance exchange. Roughly 1.4 million of those applicants were newly eligible for Medi-Cal, which was expanded to serve people up to 138 percent of the federal poverty level. About 600,000 more were previously eligible for coverage but had not enrolled. Experts say the massive outreach campaigns across the country helped alert many of these people to their eligibility.

Unanswered Questions

State health officials said about half of the 900,000 pending applications have been filed within the past 45 days—the maximum processing period typically allowed by law. Little is known about the other half, and why they have exceeded this time window.

“It’s difficult to determine exactly who is in that 900,000 and for what reason,” said Williams, the health department spokesman.

Although California experienced an initial swell of applications in December 2013, a second, enormous wave landed in March, as people scrambled to meet the deadline for obtaining insurance coverage.

“We did not anticipate the surge in applications to this extent,” said Anastasia Dodson, associate director of policy at the California Department of Health Care Services.

The state has refused to release the number of applications that were backlogged before April. “The numbers for previous months probably wouldn’t be accurate for readers,” said Dodson. Among other reasons, she said that the health department did not realize how many duplicated applications were stuck in the mix, as frustrated users tried repeatedly to sign up for Medi-Cal. “We had people who applied 30 times,” Dodson said.

The department has since identified and removed duplicate applications to arrive at the figures that have been reported since April.

Though details remain sketchy, one problem was delayed development of an interface that would connect the state’s new system with old county-based social services computer systems for verifying Medi-Cal eligibility. Some people were able to sign up smoothly by applying in-person at county health departments. But many applications submitted through the state website stalled.

Some applications have been delayed by missing or inaccurate information. Others have been slowed by outdated procedures for verifying residency—only recently replaced by an automated verification system.

Critics say that launching the Covered California insurance exchange was made a higher priority than improving the online enrollment process for Medi-Cal patients, despite their great numbers.

“In a very short period of time, there was a lot of work to do, and I think the folks that make the priorities decided that the particular piece for Medi-Cal recipients could wait,” said Frank Mecca, executive director of the County Welfare Directors Association of California.

Uncertainty For Providers And Patients

Although open enrollment for private insurance plans closed in April, Medi-Cal enrollment remains open year-round, leaving little breathing room for health officials.

The holdup in Medi-Cal approvals has led to financial uncertainty for many of California’s community health clinics, which depend on Medi-Cal payments to supplement the reduced fees or fee waivers they accept from low-income, uninsured patients. A number of centers have recently expanded facilities, staff and services in anticipation of a wave of Medi-Cal patients and the extra cash they would bring.

“We basically don’t know if we’re going to be receiving payment for the services we’re providing,” said Carmela Castellano-Garcia, chief executive of the California Primary Care Association, which represents more than 1,000 community clinics and health centers. Private providers are even more wary.

“A typical private practice might say, ‘You’re uninsured,’ and be unwilling to participate in that bureaucracy of claims that need to be paid retroactively,” said Dylan Roby, a health policy professor at the University of California, Los Angeles. Patients, too, have been left in limbo.

“They’re afraid they may not be approved and that they’ll be stuck with this huge bill,” said Irais Bazan, an enrollment and eligibility manager at Ravenswood Family Health Center in East Palo Alto.

Rodriguez said he that he did not know about his retroactive payment options when he visited a county hospital in San Mateo two months ago for his muscle and joint pains. He borrowed money from his brother to pay off the $1,400 bill—much larger than he had expected.

He could not afford the pain medications that the doctor prescribed. He still does not have a diagnosis and said he will not try again until his Medi-Cal card arrives.

Thomas Kurthy of Los Angeles is waiting for his Medi-Cal card so that he can get a physical and a colonoscopy. His father was recently treated for cancer, and Kurthy said he wants to stay on top of his health. 

His last doctor’s visit was in 2012. Since January, the 51-year-old garden designer has amassed a large folder of notes as he has tried to follow up with local health advocates, navigators, county health workers, and others who at various times have handled his Medi-Cal application.

“I’ve been bounced around from office to office, person to person,” said Kurthy. “I think if I didn’t stay on top of this, I would never hear from anybody.”

Last month, a county health worker told Kurthy that his application had a good chance of being decided within the next 30 to 45 days.

Helen.H.Shen@gmail.com

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