Why was a pregnant, sick mother of three mistakenly kicked off Medi-Cal?
(John Walker/Fresno Bee)
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 low-income 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and government officials say problems such as this continue to occur throughout the state, and are often connected to outdated and disparate computer enrollment systems.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 Medi-Cal 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 Medi-Cal 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 2015-17, 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 pregnancy-related 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.
“For somebody, that can be a life-and-death situation,” she said.
Follow the USC Center for Health Journalism Collaborative series "Uncovered California" here.