Preg­nant woman kicked off Medi-Cal by mis­take isn’t the only one

The Fresno Bee (Sunday) - - Front Page - BY YESENIA AMARO ya­[email protected]­nobee.com Cen­ter for Health Jour­nal­ism News Col­lab­o­ra­tive

Sylvia Valen­zuela was in bed for two months early in her preg­nancy be­cause of se­vere nau­sea and vom­it­ing caused by a rare con­di­tion. At a time when she des­per­ately needed on­go­ing med­i­cal care, the Fresno res­i­dent says she sud­denly lost her Medi-Cal cov­er­age through no fault of her own.

The 32-year-old mother of three, who comes from the Pas­cua Yaqui Tribe in Ari­zona, tried to stop her­self from cry­ing as she re­called the “dif­fi­cult” and “un­fair” process of try­ing to ob­tain Medi-Cal, Cal­i­for­nia’s Med­i­caid pro­gram for low­in­come res­i­dents.

Medi-Cal in­formed Valen­zuela, now eight months preg­nant, in a let­ter in late Au­gust that she was in­deed el­i­gi­ble based on her fam­ily in­come and that her cov­er­age was retroac­tive to Fe­bru­ary, when she had first ap­plied.

But the de­lay in pro­cess­ing her orig­i­nal

ap­pli­ca­tion and ap­par­ent er­ror in drop­ping her cov­er­age in July left Valen­zuela with­out med­i­cal in­surance dur­ing a sig­nif­i­cant stretch of her preg­nancy, when she be­came sicker and sicker. Ex­perts and gov­ern­ment of­fi­cials say prob­lems such as this con­tinue to oc­cur through­out the state, and are of­ten con­nected to out­dated and dis­parate com­puter en­roll­ment sys­tems.

“It was pretty up­set­ting,” Valen­zuela said. “I don’t know how they got tan­gled up, but (the Med­i­Cal rep­re­sen­ta­tive) was call­ing to tell me they made a mis­take on my case.”

A county health care of­fi­cial de­clined to dis­cuss the specifics of Valen­zula’s case but did ac­knowl­edge that there had been “is­sues” re­lated to Medi-Cal’s en­roll­ment sys­tems that might have af­fected her cov­er­age, and that she had been el­i­gi­ble for preg­nancy-re­lated cov­er­age all along.

In many in­stances, a statewide sys­tem will show cases as dis­con­tin­ued or puts them on hold, “but in real­ity cases are still open and ap­proved,” ac­cord­ing to Ch­ester Prince, pro­gram man­ager at the Fresno County Depart­ment of So­cial Ser­vices, which over­sees Medi-Cal in the county.

Peo­ple who be­lieve their cov­er­age has been wrongly dropped or de­nied should con­tact a county case­worker to re­view their eli­gi­bil­ity, Prince said.

“His­tor­i­cally, there have been is­sues with en­roll­ment that have been caused by the state and county IT sys­tems not talk­ing to each other well,” said Lau­rel Lu­cia, health care pro­gram di­rec­tor at the UC Berke­ley Cen­ter for La­bor Re­search and Ed­u­ca­tion.

Valen­zuela says she first dis­cov­ered that her Med­i­Cal cov­er­age had been dropped when her ben­e­fits card was de­nied at an ul­tra­sound ap­point­ment in July. When she called, she was told she had been dropped from Medi-Cal af­ter hav­ing been ap­proved in May.

Prince asked for a pa­tient con­sent form signed by Valen­zluela in order to dis­cuss the de­tails of her case fur­ther. When pro­vided with the form, he said he couldn’t dis­cuss her case af­ter all, cit­ing con­fi­den­tial­ity laws.

Prince did say the prob­lem was caused mainly by in­con­sis­ten­cies in Valen­zuela’s in­for­ma­tion across Medi-Cal en­roll­ment sys­tems. That has since been ad­dressed, he said.

“She’s been el­i­gi­ble from the be­gin­ning,” Prince said. But he would not con­firm whether Valen­zuela’s cov­er­age had in­deed been dropped dur­ing her preg­nancy, cit­ing con­fi­den­tial­ity laws, and di­rected a re­porter to ask her.

That’s what the Cen­ter for Health Jour­nal­ism News Col­lab­o­ra­tive did.

Valen­zuela says she can’t count the num­ber of times she called Medi-Cal. She says she first ap­plied some­time in Fe­bru­ary, when she was nearly two months preg­nant.

“I even cried to (a Medi-Cal staffer), and told him my sit­u­a­tion, spoke to nu­mer­ous su­per­vi­sors, and all they could tell me is that they had a heavy load,” she said.

PAPER­WORK ER­ROR, MED­I­CAL NIGHT­MARE

Valen­zuela had been re­ceiv­ing pri­mary care through an In­dian Health Ser­vice clinic, but she ap­plied for Medi-Cal be­cause she needed to see an OB-GYN and spe­cialty care wasn’t avail­able to her through the IHS-tribal clinic. She be­gan ex­pe­ri­enc­ing symp­toms sim­i­lar to her pre­vi­ous preg­nan­cies, when she had a con­di­tion known as hy­per­eme­sis gravi­darum, or HQ , which causes ex­treme nau­sea and vom­it­ing.

Dur­ing her pre­vi­ous preg­nancy, she re­quired a nurse at home to ad­min­is­ter IV flu­ids.

While she waited for months for Medi-Cal to process her ap­pli­ca­tion, Valen­zuela says, she spent two months in her room, un­able to get out of bed and some­times vom­it­ing up to 50 times a day. She lost about 50 pounds in four weeks, she said

“I can’t even re­mem­ber how my chil­dren lived. I couldn’t care for my chil­dren,” she said. “Even to get up and go to the re­stroom, I had to wait for my hus­band or wait for my mom to get me there. That’s how weak I was. I couldn’t move. I couldn’t stand on my own two feet.”

Valen­zuela also ended up at the hos­pi­tal twice — once with a blad­der in­fec­tion and again when she started bleed­ing and feared she was hav­ing a mis­car­riage. The bleed­ing was caused by a con­di­tion called pla­centa pre­via, which re­sults when the baby’s pla­centa cov­ers the mother’s cervix.

When she was al­most four months preg­nant, she says, her hus­band couldn’t take see­ing her like that any­more and sought out an OB-GYN, and she re­ceived some lim­ited care.

Given that she has a high-risk preg­nancy, Valen­zuela was con­cerned she could go into early la­bor dur­ing this pe­riod when she lacked in­surance.

MEDI-CAL ER­RORS, DE­LAYED CARE

Valen­zuela says that af­ter ini­tially ap­ply­ing for Medi-Cal in Fe­bru­ary, her cov­er­age fi­nally be­gan in May, when she was al­most five months preg­nant. But she says her cov­er­age lasted only about a month and a half be­fore she was no­ti­fied she no longer qual­i­fied based on her in­come.

She didn’t get any pre­na­tal care for the crit­i­cal first four months of her preg­nancy. De­spite the gains in health care cov­er­age since the im­ple­men­ta­tion of the Af­ford­able Care Act, Valen­zuela’s sit­u­a­tion is far from unique. From 201517, one in three women na­tion­ally who be­came preg­nant ex­pe­ri­enced a dis­rup­tion in health in­surance from pre­con­cep­tion to post­par­tum, re­searchers re­cently re­ported in a HealthAf­fairs blog post.

Reg­u­lar Medi-Cal ap­pli­ca­tions must be pro­cessed within 45 days, but if some­one has an im­me­di­ate need for care, coun­ties can process the ap­pli­ca­tion to al­low the per­son to ac­cess med­i­cal care the same day, said An­thony Cava, spokesman for the Cal­i­for­nia Depart­ment of Health Care Ser­vices.

Her hus­band, the only worker in the house­hold, makes about $70,000 a year, and pro­vides for the cou­ple and their three chil­dren, ages 4, 5 and 16. Although that fam­ily in­come is typ­i­cally too high to qual­ify for stan­dard Medi-Cal cov­er­age, women can ob­tain med­i­cally nec­es­sary preg­nan­cyre­lated ser­vices if their fam­ily in­come is at or be­low 213% of the fed­eral poverty line.

In Valen­zuela’s case, based on the num­ber of chil­dren, in­clud­ing her un­born child, and adults in her im­me­di­ate fam­ily, that means she would be el­i­gi­ble as her in­come was be­low the thresh­old of $73,677. The cov­er­age is ac­tive through­out the preg­nancy and 60 days af­ter birth.

Her hus­band, a cor­rec­tional of­fi­cer for Fresno County, looked into the pos­si­bil­ity of en­rolling the fam­ily in his em­ployer’s in­surance, ac­cord­ing to Valen­zuela, but found that the most eco­nom­i­cal plan would cost around $400 ev­ery two weeks, with a $6,000 annual de­ductible.

That’s some­thing they couldn’t af­ford, she said. “There’s no way we could have made ends meet.”

SYS­TEMS NOT ON THE SAME PAGE

In Cal­i­for­nia, Medi-Cal en­roll­ment in­creased by 35% be­tween 2013 and 2014 as a re­sult of its ex­pan­sion un­der the Af­ford­able Care Act, ac­cord­ing to a 2015 study. At that time, is­sues with the var­i­ous en­roll­ment sys­tems came to light.

Coun­ties use three sys­tems to de­ter­mine eli­gi­bil­ity and man­age cases, UC Berke­ley’s Lu­cia said. Two of those sys­tems feed into a third statewide sys­tem, which con­sol­i­dates all in­for­ma­tion and tracks who’s en­rolled. But the in­te­gra­tion has been un­even, cre­at­ing prob­lems like Valen­zuela’s.

“The state is in the process of mov­ing to­ward a sin­gle con­sol­i­dated sys­tem, CalSAWS (Statewide Au­to­mated Wel­fare Sys­tem),” she said. “I think there has been ac­knowl­edge­ment that there needs to be im­proved com­mu­ni­ca­tion be­tween dif­fer­ent IT sys­tems in the state.”

Neigh­bor­hood Le­gal Ser­vices of Los An­ge­les filed two law­suits over wrong­ful Medi-Cal ter­mi­na­tions across the state, in 2015 and 2016.

“We do hear from time to time that some­thing goes wrong,” said Jen Flory, a pol­icy ad­vo­cate at the West­ern Cen­ter on Law and Poverty, adding that a “county worker can’t al­ways fig­ure out what’s go­ing on.”

Her or­ga­ni­za­tion rec­om­mends that peo­ple go to a lo­cal non­profit le­gal ser­vice agency if they are con­cerned that their cases are be­ing mis­han­dled. Prob­lems nav­i­gat­ing the en­roll­ment sys­tems could mean de­layed ac­cess to care.

JOHN WALKER [email protected]­nobee.com

Sylvia Valen­zuela holds an ul­tra­sound of her son taken last month. The Fresno woman, of Na­tive Amer­i­can her­itage, was told she was el­i­gi­ble for Medi-Cal but later dropped from the pro­gram be­cause of an er­ror, leav­ing her with­out med­i­cal cov­er­age dur­ing part of her preg­nancy.

JOHN WALKER [email protected]­nobee.com

Sylvia Valen­zuela, 32, said she be­gan ex­pe­ri­enc­ing symp­toms of hy­per­eme­sis gravi­darum, which causes ex­treme nau­sea and vom­it­ing, early in her preg­nancy.

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