Medi-Cal Beneficiaries Should Be Guaranteed the Right to Independent Medical Examinations – State of Reform

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Under current California law, beneficiaries of commercial health insurance are entitled to an independent medical review (IMR) of any services their health plan has refused to provide after deeming them “medically unnecessary.” California’s Medicaid program, however, does not guarantee the same rights to all its members.

The 4 million of California’s 13 million Medi-Cal beneficiaries who are not enrolled in managed care or using a managed care plan regulated by the Department of Managed Health Care are not eligible for IMR. A invoice going through the legislature aims to change that, and based on its completely unanimous support so far, it will likely become law soon.

The bill was introduced last year and, as a member of staff of the sponsor of the bill Asm. Marc Levine’s (D-Santa Rosa) office told State of Reform that it went through several changes that were mostly suggestions from committee hearings and intervenors. They noted that the amendments do not significantly alter the general purpose of the legislation.

RMIs guarantee patients the right to have an independent panel of physicians review a refusal of medical service. Currently, about 4 million Medi-Cal beneficiaries can only appeal decisions through state fair hearings rather than IMRs. These hearings require patients to identify and bring in their own expert medical witness to assess the need for services, while RMIs provide such a representative for the patient.

The state’s fair hearings are presided over by an administrative law judge instead of a panel of doctors, who have “legal rather than clinical expertise,” as Linda Nguy, senior policy attorney at the Western Center, explained. on Law and Poverty, during his testimony in favor of the bill.

“[Using State Fair Hearings for these cases] is problematic because then you have an administrative law judge with no medical training or clinical experience who evaluates medical evidence such as patient records, medical journals, studies and lab tests to determine medical necessity,” said Liza Thantranon, regional health attorney at Legal Services of Northern California.

According to Levine’s office, 60% of IMRs allowed patients to receive the service they were initially denied, while only 28% of State Fair Hearings did.

Under the bill, Medi-Cal beneficiaries will be able to challenge denials, delays, or changes to medical services through an IMR process beginning January 1, 2023. Patients will be able to appeal disputed medical decisions up to 6 months after receiving the supplier. decision.

If enrolled in Medi-Cal Managed Care, the patient must first apply directly to the plan. If the plan does not respond within 30 days, or if the Director of the Department of Health Care Services (DHCS) waives the obligation to call the health plan due to the emergency, then the patient may appeal directly to DHCS. A patient may appeal an IMR decision within 90 days of its issuance.

The bill requires DHCS to enter into a contract with one or more IMR organizations to implement its provisions. The agency is also required to post information about the IMR appeal process and an appeal form on its website for grantees to access.

So far, it has not received any ‘no’ votes in the Legislative Assembly and no opposition organizations have been registered. After unanimously passing the Assembly in January 2022 and the Senate Health Committee last week, it should soon receive a full vote in the Senate.

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