Samantha P. Hawthorne
Staff Writer
9/24/2013
As of Sept. 1, Medi-Cal patients who reside in Lassen County but are seen by primary care physicians in Plumas County are no longer eligible for Medi-Cal reimbursement for those services. The same holds true for Plumas County residents who have a Lassen County primary care physician.
The change is a result of the implementation of the Medi-Cal Managed Care system, which allows counties to choose from three models of managed health care plans. The model chosen designates the insurance provider that will cover beneficiary care. Under this new system, Lassen and Plumas counties chose different models, which has caused a rift in the patients eligible to be seen.
According to Seneca Healthcare District Chief Executive Officer Linda Wagner, Plumas County chose Medi-Cal’s two-plan Local Initiative model, which allows beneficiaries to choose either Anthem Blue Cross or California Health and Wellness Plan as their insurance provider. The LI model is designed to meet the needs and concerns of the community.
Lassen County chose the County Organized Health Systems, which uses Partnership Health Plan as its insurance provider. The COHS model is run by the county and all beneficiaries within the county are required to use the same provider. According to Northeastern Rural Health Clinics Operations Director Janice Brinkman, only Northeastern Rural Health Clinics and Susanville Indian Rancheria are affected by the managed care systems.
According to dhcs.ca.gov, “Managed care plans are a cost-effective use of health care resources that improve health care access and assure quality of care.” In the case of Seneca, however, this has not proved to be so.
Seneca patients who live on the border of the two counties, specifically Clear Creek and Westwood, are now at a crossroads. Since Medi-Cal Managed Care is county-based, those who live in the aforementioned towns are unable to continue seeing their primary care physicians.
Wagner said that ever since Lassen contracted with Partnership Health Plan on Sept. 1, patients affected have been using Seneca’s emergency room services in order to see their physician. These visits are still covered under Medi-Cal since ER visits are not affected by the managed care plans. Wagner said the use of these services for nonemergencies is costly, however, which defeats the purpose of the Medi-Cal Managed Care plans.
Wagner said she is working hard in order to find a solution for Seneca patients who are Lassen County residents.
“We asked Partnership Health Plan to extend its contract to established Seneca patients only, who are on the county boarder,” she said.
Upon speaking with Darryl Crowder, senior provider contracts manager for Partnership Health Plan, Wagner was told that an exception for these patients was not possible because the program is county-based.
Crowder suggested patients contact Joan Russell, manager of provider education, to complain about the situation and see if anything can be done. She can be reached at 707-863-4229. Alternatively, Medi-Cal beneficiaries can call membership services at 707-863-4120.
According to one of Seneca’s Lassen County patients, upon explaining her extenuating circumstances she was directed to call 800-863-4155 and ask for an exception based on “specialty care.” They told her that they would make the exception but Seneca would have to bill them directly, rather than have Medi-Cal bill them, as is customary.
Wagner said that anyone who thinks he or she may qualify under this exception should contact the 800 number listed above. Repeating the popular saying, “the squeaky wheel gets the grease,” she emphasized how important it is for beneficiaries to call and express their concern to PHC at any of the aforementioned numbers.
She said that Medi-Cal representatives also informed her there was nothing they could do, and anyone with issues would have to speak with county providers directly. They said that this issue is unique to a small group of people and because of this, it is unlikely to become a noticeable issue for at least a couple years.
Among the steps taken in an attempt to alleviate the situation, Wagner researched the possibility of placing a clinic in Westwood. Her research was in vain, however, as she soon learned that this would not fix the problem since Seneca’s main office is located in Plumas County.
“We are doing everything we can to make a change, but right now the only option for Lassen County residents receiving Medi-Cal is to go to a Susanville provider for primary care in order to have your visit paid for,” said Wagner.
Northeastern Rural Health Clinics in both Susanville and Westwood are currently accepting new patients in order to provide health care for those displaced Seneca patients.
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