Medicare has one set of rules about how beneficiaries can appeal medical decisions and Medi-Cal, California's version of Medicaid, has a completely different set of appeal rules.
Federal and state officials are busy designing an integrated care system for people who receive both Medicare and Medi-Cal benefits –known as dual eligibles – which is expected to cut down on redundancy, make care decisions less confusing and save money. When that conversion of duals happens, which appeals rules will apply?
That's the question addressed in a policy brief published yesterday by the National Senior Citizens Law Center.
"We think beneficiaries should continue to receive benefits during an appeals process and they should have direct access to an external appeal," deputy director Kevin Prindiville said from the NSCLC office in Oakland. "Those are not under Medicare currently, though they are the rules for Medi-Cal."
California's duals project is still in its infancy, so it is unclear whether the current Medi-Cal rules will eventually be adopted under the new guidelines for dual eligibles, according to policy brief co-author Georgia Burke.
"If you have an integrated model of care," Burke said, "appeals protections should be available regardless of where that coverage originates. California is actually pretty good on appeals rules. We're asking the new models for dual eligible care to extend themselves to those rules."
Prindiville said because this state has strong appeals rules in place now, that doesn't mean Californians will get the same treatment under new rules.
"It is a worry," Prindiville said, "because they haven't figured it out yet. There are two statutes of policy, and the state is going to have to come up with a blended version."
That blended version will be complicated by federal involvement, Prindiville said. "The question is, how much will they be allowed to change things on the Medicare side?" he said.
"These people don't have the ability to use a credit card and get care now and worry later," Burke said. "They need pay pending while they're going through appeal, and they need an expedited path for medical emergencies. Duals are so dependent on these programs, they really need to have something they can navigate easily and quickly."
Jane Ogle, deputy director of Health Care Delivery Systems at the state Department of Health Care Services, said DHCS is still soliciting input on the dual eligible project, and yesterday's policy brief is certainly part of that.
"We found the brief to be very helpful in guiding discussions and we look forward to continued work with NSCLC as the duals integration project moves along," Ogle said. "We are establishing a beneficiaries protection workgroup that will be addressing the individual issues raised throughout the process."
The NSCLC is in an unusual position with DHCS, in that it is one of the litigants challenging the legality of the state's transition program for adult day health care patients. The shift of roughly 35,000 dual eligible patients in ADHC to managed care plans is a different issue, Prindiville said.
"It's not doing what the duals process is doing," he said. "With ADHC patients, they're not talking about full integration of benefits, it looks nothing like the duals project."
So far, Prindiville said, he has liked much of the discussion of the duals project. "It's been careful and thorough and thoughtful," Prindiville said.
"I think they're on the right path, in terms of what we're hearing from them," he said. "They're still soliciting ideas. So there are a lot of key decisions still to be made."