By Dr. Mitesh Popat, Venice Family Clinic CEO

Originally published in CalMatters, March 28, 2023

An error caused a Venice Family Clinic patient to lose the Medi-Cal coverage that paid for her HIV medications. People living with HIV must take their medications as prescribed to stay healthy, so she moved quickly to remedy things.

She went directly to the L.A. County Department of Public Social Services, or DPSS, which administers Medi-Cal, the state’s version of Medicaid, and provides coverage for people with low incomes, including 1 in every 3 Californians.

When the in-person meeting didn’t resolve the issue, she turned to insurance specialists at Venice Family Clinic, a nonprofit community health center serving 45,000 low-income people in L.A. County. But even our specialists struggled to fix the problem because L.A. County’s antiquated and inadequate system usually requires a telephone call – and often multiple calls – to correct Medi-Cal errors and coverage issues.

In this case, correcting the error required a two-hour call by our specialist, a case inquiry email and four more follow-up calls on separate days. All the while, the patient waited 23 days to get her Medi-Cal coverage restored. Fortunately the clinic’s Common Ground program, which offers HIV prevention and treatment, was able to help provide HIV medications while she waited for reinstatement.

This frustrating process to correct a simple coding error illustrates how overwhelmed the county’s telephone system already is, and upcoming Medi-Cal changes promise to swamp this system if improvements aren’t made quickly. Beginning Saturday, L.A. County will start notifying approximately 300,000 people that they will lose their Medi-Cal coverage if they don’t go through the process to re-qualify.

During the pandemic, the federal government instituted a continuous coverage program to keep people enrolled, but this program is now ending. In Los Angeles County, it’s estimated that as many as 20% of the people who will lose their Medi-Cal coverage will actually still be qualified for the program. Getting their coverage reinstated will require a phone call to an already overburdened telephone system.

Officials estimate as many as 3 million people statewide could lose their benefits from the shift back to annual eligibility checks.

And there’s even more enrollees on the way. Next year California will expand Medi-Cal eligibility to adults with low incomes who are ages 26 to 49 regardless of their immigration status. In L.A. County, approximately 70,000 patients currently served through the My Health LA program will become newly eligible for Medi-Cal.

This skyrocketing demand for services will inundate local departments like DPSS if they don’t act quickly to hire more agents and upgrade their phone and computer systems to allow patients to make simple changes online. Right now, it takes a phone call, often with the patient waiting on the line, to quickly change an address, submit verifications or correct an incorrect code – like the one that prevented our patient with HIV from getting the medications she needed.

No one has time for this. Many patients often work or have family obligations that make long waits on the phone impossible. It also burdens health care staff who could be addressing other needs.

DPSS and others need to work quickly to avoid being swamped by the coming tidal wave of new enrollees and people who need their Medi-Cal benefits restored when the pandemic-era continuous coverage program ends.

Overtaxing a system already overwhelmed by current demands could leave Medi-Cal recipients without the health care, medications and other services they need. As the pandemic vividly demonstrated, the health of the entire community depends on the health of each individual.