The third phase of the Healthy Families transition begins today, and it could be a bumpy passage.
The first two phases moving about 615,000 Healthy Families children to Medi-Cal managed care plans have gone relatively smoothly, with almost all of those children retaining their health plan and roughly 94% of them retaining their primary care physician, according to the Department of Health Care Services, which is overseeing the transition.
Medi-Cal is California's Medicaid program, and Healthy Families is its Children's Health Insurance Program.
The stark exception to "smoothly," however, has been an extended fight over the loss of coverage for a specific kind of autism treatment because of the transition.
Now comes the harder part of the transition. Phases 3 and 4 have smaller numbers of children to transition, but are expected to have higher rates of disruption in continuity of care. More children are expected to change both health plans and providers.
The first phase involved kids covered by insurers that also provide Medi-Cal managed care plans. The second-phase kids are in plans that subcontract with Medi-Cal plans, so few of them switched plans or had to change primary care providers. The third phase involves children covered by insurers that neither offer nor contract with Medi-Cal managed care plans. Children in the fourth group live in counties with no Medi-Cal managed care plans.
The difficult stages of the transition kick off amid criticism of the way the Department of Health Care Services handled part of the transition, specifically in connection to a change in the way an autism service called applied behavioral analysis, or ABA therapy, is delivered.
ABA therapy is not covered by Medi-Cal. Children moving from Healthy Families to Medi-Cal can apply for ABA therapy through a series of regional centers contracted by the state. Because eligibility criteria are more stringent at regional centers than in Healthy Families, advocates expect about three out of four families requesting ABA therapy will be denied.
More Difficult Transitions Begin Today
With the exception of the fight over autism services, the first two phases of the Healthy Families transition have been relatively controversy-free.
According to DHCS statistics, fewer than 1% of children had to switch health plans and only about 6% of children had to change primary care physicians during the first two transition phases.
That represents few problems in the move for 615,000 children, about three-quarters of the total number of kids who will make the transition.
"I believe unequivocally the department has been successful [in the transition]," said Rene Mollow, deputy director of benefits and eligibility at DHCS. "We've been able to transition a large number of children, and those kids have been able to access services with a minimum of disruption."
Mollow said federal rules require the department to monitor the transition, including contacting families who have made the transition, and that's where you see proof of success, she said.
"As we look back on the monitoring reports, it demonstrates we've been able to maintain access and minimize disruption," Mollow said. "We never went into this saying we'd have no disruptions in care. Our goal has always been to minimize disruption, and we've done that."
That makes sense to Suzie Shupe, executive director of the children's advocacy group California Coverage and Health Initiatives, who said the first two phases of the transition were expected to go smoothly.
"This is consistent with what the department was saying all along. Those numbers don't surprise me," Shupe said. "But we have seen some continuity-of-care issues, even in the first two phases. And in phases 3 and 4, a huge number of children will be changing health plans and finding new providers."
Phase 3 of the transition started today.
Phase 4 Smallest but Expected To Produce Most Change
Mollow agreed the next phases will be the more difficult ones. "Of all the phases, 4 is the one with the most change," she said, "with a new health plan and a new primary care provider."
The number of children in phase 4 is relatively small, though, with about 35,000 of them in that last stage of the transition. About 110,000 children will make the switch during Phase 3.
Shupe is concerned that there may not be enough notification and preparation for the more difficult phases of the transition.
"That's a big focus for us right now," Shupe said. "We think there was some missed opportunities to get that information out to parents and providers before phase 3 started."
A sheet of frequently asked questions was released by DHCS on July 19 to providers.
Shupe said many of the children in phase 3 have chronic conditions, meaning that continuity of care becomes much more important.
"My concern is, when children are healthy, they have time to change providers, it's not as much of a continuity-of-care issue. It's where a child who has a chronic condition, or someone scheduled for surgery or some medical procedure, those are what causes concern in phases 3 and 4."
The department's FAQ, she said, "is a step in the right direction, but really, it should've happened earlier," Shupe said. "It's incumbent on the state to get that information out to parents and providers in a clear and concise way."
Once the phase 3 transition gets fully underway in August and September, she said, "I imagine we're going to be hearing some stories."