Lawsuit Slams the State's Duals Project

by David Gorn

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Stakeholders last week filed a lawsuit in Superior Court lambasting Cal MediConnect, the dual eligibles demonstration project that is part of the state's Coordinated Care Initiative.

The state is hoping to enroll approximately 456,000 duals -- about half of the state's 1.1 Californians who qualify for both Medicare and Medi-Cal benefits -- into Medi-Cal managed care plans.

As part of that effort, the state has sent out "choice forms" to duals recipients, where they can select a Medi-Cal managed care plan or elect to remain in their current fee-for-service plan. If duals recipients don't make a choice, they are automatically and passively enrolled into Medi-Cal managed care.

This month, passive enrollment started in Los Angeles County -- the county with the biggest population of dual eligibles in the state -- and on July 1 the state reported 26,759 duals in L.A. County were enrolled (actively or passively) in Medi-Cal managed care programs.

That process is misleading and confusing, according to the lawsuit filed July 2 in state Superior Court in Sacramento by the Los Angeles County Medical Association, three independent living centers in the county and an ophthalmologist based in Chula Vista. They said the frail, elderly and often cognitively impaired patients in the duals project have been harmed by inadequate readiness of implementation by the state, which the lawsuit said was confirmed by CMS review.

"This program has caused vast confusion among these patients," the lawsuit said. "At the same time, regulators have discovered various plans approved to participate in the program have had inadequate networks, or received low quality scores or failed to meet solvency requirements. Yet [state officials] have insisted on implementing the CCI -- even in the absence of statutory authority to do so."

The lawsuit was referring to problems in several of the eight counties in the duals project. Enrollment in Orange County was postponed till at least the start of 2015 because of network adequacy issues that have kept Optima from enrolling duals in that county till adequacy questions are addressed. Alameda County also is delayed till at least 2015 because of solvency issues. And the largest insurer in Los Angeles County, LA Care, will be able to enroll duals now -- but cannot passively enroll duals until 2015 because of low Medicare quality scores.

Five counties have launched passive enrollment efforts so far: San Mateo started in April; Riverside, San Bernardino and San Diego counties started in May; and Los Angeles County's passive enrollment began July 1.

The lawsuit said the state is required to have a choice form that is at or below sixth-grade reading level, and that the choice to opt out of the program also is clear.

"Not surprisingly, an incidental effect of these failures to perform mandatory, non-discretionary duties imposed by statutes," the lawsuit said, "has been widespread confusion, threatening the continuity of care for many dual-eligible beneficiaries who suddenly might find or actually do find themselves 'passively' enrolled in a ... managed care plan, and unable to see their preferred physician or other health care provider."

The stakeholders are asking the court for a preliminary injunction to halt passive enrollment and implementation of the CCI.

William K. Averill
Disclosure: I am on the Executive Committee of the Los Angeles County Medical Association. LACMA, representing LA County physicians from every medical specialty and practice, is a party to the suit.
William K. Averill
The volume of patients affected by the CCI, and the confusing passive enrollment of the most vulnerable patients is unacceptable. The cost to healthcare quality will be shouldered by those who can least afford to carry the weight of bureaucracy.

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