Medi-Cal Patients with neurological disorders, cancer, end-stage renal disease, and rare genetic conditions are forced into managed care over doctors’ objections

LOS ANGELES—Jane H., a 52-year-old Medi-Cal recipient with multiple sclerosis, drives all the way to San Diego to see her neurologist—one of just a few doctors who can administer the specialized treatment preventing her disease from relapsing. The treatment has made a big difference in Jane’s life: she was able to get out of her wheelchair and, eventually, to stop using a walker. That’s why an administrative law judge exempted her from having to transfer to a Medi-Cal managed care plan, where she would no longer have access to the same care.

But the state’s Department of Health Care Services decided to reverse the judge’s decision and ignore the medical evidence—including letters from her doctor predicting her condition will worsen if her treatment is disrupted.

“It doesn’t make any sense. It’s not like I have diabetes and I can just go to any doctor to get my insulin,” she said. “I could rebound, and I don’t know that I would be able to bounce back from that.”

The State is unlawfully forcing some of the most medically-vulnerable Medi-Cal beneficiaries into managed care plans, where they can no longer receive the care they need to treat serious, often life-threatening conditions.

Under state rules, people on Medi-Cal can request a temporary exemption from enrollment in a managed care plan if their doctors determine that their health would suffer if their current care is disrupted. But even when an administrative judge determines a patient needs a medical exemption from managed care enrollment—a rare decision that follows a long and difficult process—the Department often overturns the decision.

“The Department is failing to follow its own standard, even after the treating doctor and a neutral arbiter have determined that the patient is too unstable to leave the doctor’s care,” said Mona Tawatao, an attorney with Western Center on Law & Poverty.

Jane H. and other patients filed a lawsuit yesterday seeking a court order to stop the Department’s unlawful practices.

Attorneys at the Western Center on Law and Poverty and Neighborhood Legal Services of Los Angeles County, who represent these patients in a lawsuit, estimate that the state has improperly reversed 40-50 percent of administrative judges’ decisions granting an exemption from managed care over the past two years.

“Those seeking exemptions from managed care are among the sickest, most vulnerable people in the Medi-Cal program,” said Neighborhood Legal Services attorney Ella Hushagen. “They have complex autoimmune and neurological disorders, cancer, end-stage renal disease, and rare genetic conditions. It has taken many of them years to find doctors who can treat their conditions, and losing these doctors means risking a rapid and dangerous decline in their health.”

Read coverage of the lawsuit in Kaiser Health News