Mon. Nov 28th, 2022

Community Health Group, San Diego’s oldest health plan for Medi-Cal recipients, has appealed a state consolidation decision that would erase the local carrier from the coverage map and force about 330,000 current members to choose a different plan starting in 2024.

Supporters rallied outside the county administration building on Harbor Drive in San Diego Thursday morning to announce the appeal and to put public pressure on the state to modify its decision.

Joseph Garcia, Community Health Group’s chief operating officer, said CHG, which has served Medi-Cal members in San Diego County for more than 40 years, missed out by only nine-tenths of a point in the state’s rating scale.

Such a slim margin, Garcia argued, ought to be enough to keep the plan from being shut down.

“We will fight them tooth and nail all the way through to try to remain a health plan,” Garcia said. “We hope they reconsider.”

In late August, the state Department of Health Care Services chose Health Net and Molina Health care as its two operators in San Diego County, starting in 2024, shutting out Community Health Group, Blue Shield of California, Aetna and United Health Care from managing local Medi-Cal plans.

Though it has been the most public about its plan to appeal, Community is not the only plan that has filed an appeal. A document published by the DHCS in early September indicates that Blue Shield, Aetna and Health Net have also filed appeal documents. It was unclear why Health Net appealed, given that it is one of the successful providers in San Diego County.

Health Net, Molina and Kaiser all face their own additional headwinds locally, with San Diego City Attorney Mara Elliott suing all three in 2021 alleging that each misleads consumers with “inaccurate provider directories that include doctors who are not affiliated with the providers and whose work is not covered by their plans.”

Many stood up to testify to the depth of Community Health Group’s doctor network Thursday, including Chula Vista Mayor Mary Salas, Dr. Zara Marselian, president of La Maestra Community Health Centers and Dr. Mehran Moussavian, CEO of the Cardiovascular Institute of San Diego.

Moussavian said after Thursday’s event that he has been working with CHG for 17 years and has noticed a significantly easier approval process for cardiac care than has been the case with other Medi-Cal managed care plans. Appointments, he said, can generally occur within 24 or 48 hours with CHG enrollees, but may take much longer with others.

“With other plans, we have to get authorization and who knows how long it will take,” Moussavian said. “It could take a week, it could take two weeks.”

While many may not realize it, private companies administer Medi-Cal benefits for 12.3 million of the 14.6 million Californians on the state’s safety net health insurance plan.

Just as is the case in the commercial insurance world, managed care has health insurance companies that contract with a select group of doctors and other medical professionals to provide services to their beneficiaries.

Generally, those on a given managed care plan can see only contracted providers.

San Diego County has had a particularly large collection of Medi-Cal managed care plans, with seven currently offering their services across the region.

The state thinks this is too many and, under a reform process called CalAIM, it is seeking to pare the total number allowed to manage Medi-Cal plans to just two in each county, plus Kaiser Permanente, for a total of three. The idea is that, by having fewer plans, those remaining will represent larger numbers of patients, allowing more efficient operation and wider-reaching preventive measures that can help improve the collective health of entire populations of people.

Other products that those companies provide in commercial and Medicare markets would not be affected by the decision. And no Medi-Cal recipient will lose their coverage. They will just be forced to choose a different insurance plan with a potentially different selection of contracted health care providers to manage their benefits.



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