Medi-Cal’s Fragmented System Can Make Moving a Nightmare

By Bernard J. Wolfson, Senior Correspondent and columnist for California Healthline. Originally published at Kaiser Health News.

When Lloyd Tennison moved from Walnut Creek to Stockton last year, he assumed his coverage under Medi-Cal, California’s safety-net health insurance program, would be transferred seamlessly.


About three weeks before his May move, Tennison called the agency that administers Medi-Cal in Contra Costa County, where Walnut Creek is located, to inform them he’d be moving to San Joaquin County.

Little did he suspect his transfer would get tangled in red tape, disrupt his care, and saddle him with two bills totaling nearly $1,700 after he was removed from his old plan without notice before his new one in Stockton took effect.

Medi-Cal members who move counties are often bumped temporarily from managed care insurance plans into traditional Medi-Cal, also known as “fee for service,” in which the state pays providers directly for each service rendered. But managed care practitioners who don’t participate in traditional Medi-Cal have no way to get paid when they see such patients, and they sometimes bill them directly — even though that’s prohibited.

Medi-Cal is a statewide program, but it is administered by the counties, which have separate government bureaucracies and different approaches to care: Some have just one county-operated Medi-Cal plan. Others have only commercial health plans, which are paid by the state to manage the care of Medi-Cal patients. Many have one of each.

Traveling from Walnut Creek to Stockton takes a little more than an hour by car, but as far as Tennison is concerned, the two cities might as well be on opposite sides of the planet.

Tennison, 63, needed a smooth health care transition. With severe chronic pain in his back, shoulders, and neck, he requires regular physical therapy and monitoring by an orthopedist, as well as multiple pain medications. He also has carpal tunnel syndrome and Type 2 diabetes.

Because of miscommunication and confusion surrounding his move, several physical therapy appointments he’d made for June 2022 were canceled, and he had to wait nearly two months for new ones.

“To me the whole issue is the confusion,” Tennison said. “Right hand and left hand, nobody talks to each other, and nobody talked to me.”

The first hint of trouble came when he called Contra Costa County Employment & Human Services in late April 2022 to report his upcoming move and was told the new county had to initiate the transfer — only to hear from a worker at San Joaquin’s Human Services Agency that it was the other way around.

They were both wrong: Medi-Cal members who move can inform either county.

Tennison persuaded a Medi-Cal worker in San Joaquin County to initiate the transfer. He also filed a notice of his move online, which Medi-Cal workers in Contra Costa processed and flagged for a June 2 transfer date, said Marla Stuart, director of the county’s Employment & Human Services Department.

They set that date, Stuart said, because they believed Tennison might have some medical appointments in May under his Contra Costa Anthem Blue Cross plan.

Medi-Cal workers in San Joaquin County, however, set a move date of May 5, which overrode Contra Costa’s June 2 date and bumped Tennison from his Anthem plan for most of May, according to Stuart.

“If anybody had called me to verify any of this, I definitely would have told them May 5 was the wrong date,” said Tennison, who moved to Stockton on May 17.

“There were good intentions all around,” said Stuart. “It’s unfortunate what happened.”

Being cut from Anthem left Tennison with fee-for-service Medi-Cal, a rapidly shrinking part of the program.

He discovered it only in mid-July, when he called the Office of the Ombudsman for managed care Medi-Cal to complain about two bills he’d received — one for $886.92 from his orthopedic surgeon and another for $795 from his physical therapist.

He had seen both providers in May, when he thought he was still covered by Anthem. But he wasn’t, and they billed him directly, despite signed agreements and a state law that prohibit billing patients for services covered by Medi-Cal.

The bills caught Tennison by surprise, because the ombudsman had told him in early June that he had still been on Anthem through May, he said.

“To me, that’s how insurance works: One insurance ends, the other begins,” he said.

When Medi-Cal patients are between health plans and temporarily in fee for service, it theoretically ensures they have ongoing access to health care. But in practice, that’s not always the case.

“Because the state is pushing most Medi-Cal members into managed care, fewer providers are accepting fee for service,” said Hillary Hansen, an attorney with Legal Services of Northern California who is handling Tennison’s case.

The prohibition against billing Medi-Cal patients is spottily enforced, Hansen said. And although the patients are not legally required to pay, she said, their credit rating can suffer if they don’t. Michael Bowman, a spokesperson for Anthem, said the company regularly communicates with its providers to ensure compliance with the terms of their contracts and Medi-Cal rules.

Hansen is not confident Tennison’s bills will be paid anytime soon. After legal aid lawyers sent a letter to state officials about improper Medi-Cal billing, and later met with them about it, the officials instructed them to have their clients submit reimbursement claims.

But the reimbursement rules require that patients have already paid the bills, and Medi-Cal beneficiaries typically can’t afford that, Hansen said.

Tennison submitted his reimbursement form in May and is waiting to hear back. “Getting medical care should not be this difficult,” he said. “Here it is a year later, and I’m still trying to work this out.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.\n

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. griffen

    Best Healthcare Evah!! America has the wherewithal to do this better, but chooses not to; that’s my conclusion after watching the rollout for the ACA in 2013. And then following all the whiplash, naturally, from Republicans at the roll out of a healthcare plan first suggested by Romney ( I wish to say, I think so ? ). Maybe I’ve assigned that memory to being associated with Massachusetts instead.

    Unbelievable, this is third world country stuff. I think Amfortas has a few anecdotes from the healthcare travails specific to the hill country of Texas, as will others. Don’t get sick and don’t be poor in America.

    1. ayy emm

      Long time reader, first time commenter.

      I wasn’t born in Massachusetts but have lived here since I think just before Mitt Romney was governor (so, after he helped run the Salt Lake City Utah Winter Olympics, well before the senate seat). Maybe it’s just a local bias but I’d always heard the same: that Mass’s “Romneycare” was in fact a template for “Obamacare”.

      Incidentally another spot of relevance to this anecdote is that Mass’s state Healthcare plans, which have just become somewhat less generous at low ends due to the end of the health emergency situation, also have complex coverage territories. In the New England town system, every square inch of the state is administered as one or another town or city. There is no unincorporated territory, and relative to most states, the counties are large and roughly vestigial.
      So, a booklet sent out this spring showed every plan, or subplan or what have you (different private operators, purposes, etc.), and where it operates, with a granular map of every town in the state (all 351)!

      As some readers will know, it’s much more important to know which town you’re in at any given time when living here than in most of the country. I think a lot of people get used to it, but it certainly suggests moving to be similarly difficult for the unprepared, except within certain bands of towns with vague shifting associations.

  2. PE Bird

    I’m surprised the counties don’t devolve administration to localities who then devolve to neighborhoods. A cornucopia of health “plans”. California certainly knows how to not act like a state when they want.

  3. JBird4049

    This fragmentation is nationwide and I assume that it is just as difficult to move from state to state as well. It is not completely insane as the system is working through the separate states who each have their own standards working from the minimum required benefits; California’s Medi-Cal (and CalFresh) is more generous than many states especially those in the South.

    Many states add to the basic package of benefits and modify as well the requirements for benefits, and while on paper the requirements for qualification are clear, there is wiggle room for interpretation meaning the emphasis by local governments on how to judge a person’s need means that the same person could be approved or not depending on which county one is in. Restated, just what you get, or if you are even approved, changes from state to state and then county to county. This includes Section 8 (public housing)

    I also have to mention the regular recertification of one’s benefits along with the threats of fines and imprisonment both written and verbal for any misuse of one’s benefits. On the surface it appears to be a system of help, but between the bureaucratic treats, checking, and recertifications, can I be forgiven for thinking that I am considered some kind of miscreant instead of a person in need of help?

    Then there are the increasing wait times for medical appointments sometimes for months and section 8 for years, even more than a decade. It is like the same whole thing is meant to punish the needy under the façade of aid.

  4. Amber

    Depending on the county too, you may find your doctor no longer covers you, or as they often do in Orange County, claim they’re no longer accepting new patients. I haven’t been able to get in to a doctor as a result despite being covered, and usually end up at the ER In desperation when sick. Its stressful. For the record I got far better care when I lived in LA county than living in Orange County.

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