Have you ever wondered how one of your Covered California accounts got changed when you know that neither you nor the client touched application? Covered California accounts are being mysteriously changed without the applicants knowledge or consent. If you check the Transaction History of the account you might find that this mysterious user known as System has updated the account without ever notifying anyone of the change.
What happen to the health plan?
It was only after an unexpected change to one of my Covered California accounts where the individual was suddenly enrolled in Medi-Cal,she had been enrolled in a private health plan, that I realized someone else was tinkering withher enrollment. When I reviewed the Transaction History of the account, a user called System had changed or updated the individuals account. When I inquired with Covered California I was informed that the user System was usually a representative from the county Medi-Cal division.
User ID: System
Additionally, the Covered California Service Center Representative told me that the counties can change the account without ever notifying them, the household or the agent. Supposedly, based on income data from state and federal sources, a county worker can drop a Covered California account members income to zero which makes them automatically eligible for Medi-Cal. The process doesnt seem to take into account that an individual may be receiving income from freelance or contract work that isnt necessarily reported through normal employment wage reports to either California or the federal government.
System user changes income without notification
In most of the cases I have researched there have been valid triggers for the review and change of the account. Most of these instances had to do with income and verification. With one account the health plan enrollment was terminated because the applicant showed no income. Initially, the radio button indicating the applicant wanted help paying for health insurance was checked. The household subsequently decided to pay for a private plan without receiving any tax credits.
CalHEERS complex program
Unfortunately the “System” determined the household was eligible for Medi-Cal and stripped the account of the health plan enrollment. This has left the individual enrolled in the private health plan they chose and newly enrolled in the countys Medi-Cal program. Short of terminating the existing account and starting a new application, Covered California has no way to fix the inadvertent selection of the Yes, I want to see if I qualify for low-cost or free health insurance button that starts this cascading action of changes by the county.
How will the System changes impact the members?
The other issue that arises is when the System changes the estimated income, it doesnt seem to terminate the existing plan. The CalHEERS program is a web of interconnected links, triggers and automatic decisions. A change to income or address will invariably trigger changes to the Advance Premium Tax Credit or which plans a household may enroll into. This all happens when a Covered California SCR, the applicant or agent submits a Change Report. Somehow when the System user changes the account, actions such as terminating an existing plan or even notifying the member are not triggered.
No APTC, no changes
The instances where the User ID of System changed the account information happened in Los Angeles County. But this is not to say it cant or wont happen in other counties. However, individuals who did not select they wanted either subsidized or free health insurance, even though they reported Medi-Cal eligible income, have not had their accounts tampered with. In addition, individuals who attested to their income amount, as far as I can tell, have not had their incomes changed or enrolled into Medi-Cal.
Transaction History and Change Log Table
To view whether a Covered California account has been changed by the System user ID open the households account and click on Summary. Then click on Transaction History and you will be able to see all the users who have changed any information in the members account.
This Transaction History shows that a Covered California Service Representative made changes to the account on July 23
The User ID of Service Center Representative indicates a Covered California employee changed the account.
In this screen shot you can see the user insuremekevin made changes on August 1st, but the user System made a host of changes back in May. These changes resulted in the loss of a private health plan, yet he has never been notified that he is eligible for Medi-Cal.
If you scroll down further in the Transaction History you will find the Change Log Table. This is the list of the actual changes that were made. In this screen shot the System user changed numerous fields in the account on July 29.
The mysterious User ID of System can make changes to a Covered California account without notifying the primary applicant of the account.
When an agent or SCR changes a field the Change Log will reflect the old and new values such as when I added a family member to the account of one of my clients.
Counties override CoveredCA
Even if the changes made by System are valid, Covered California should still notify the primary applicant that those changes are being made and allow them to appeal the decision. The response from Covered California is that the applicant needs to contact their county Medi-Cal office or withdraw participation and start a new account. Of course, withdrawing an application is fraught with problems concerning whether the household is entitled to a Special Enrollment Period under a qualifying event and if there might be a gap in coverage because of enrollment date issues.
No letter or phone call, just Medi-Cal
Covered California mandates that any changes to income, address or household size needs to be reported within thirty days. (Note -Medi-Cal requires being notified within 10 days of a change income). If primary applicants are under reporting requirements, why arent the county Medi-Cal offices also required to notify a Covered California account holder when they make a change? It only seems like common courtesy to inform a family they are enrolling them in a Medi-Cal plan they may not want or need.