Medi-Cal beneficiaries likely to be guaranteed right to independent medical reviews

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

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

 

 

The bill was introduced last year and, as a staff member from bill sponsor Asm. Marc Levine (D – Santa Rosa)’s office explained to State of Reform, it has undergone several amendments that were primarily suggestions from committee hearings and stakeholders. They noted the amendments don’t significantly alter the overall purpose of the legislation.

IMRs guarantee patients the right to have an independent panel of physicians review a medical service denial. Currently, around 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 evaluate the necessity of the services, while IMRs provide such a representative for the patient.

State Fair Hearings are presided over by an administrative law judge instead of a panel of physicians, who have “legal rather than clinical expertise,” as explained by Linda Nguy, Senior Policy Advocate at the Western Center on Law and Poverty, during her testimony in favor of the bill.

“[Using State Fair Hearings for these cases] is problematic because you then have an administrative law judge with no medical training or clinical experience evaluating medical evidence such as patient records, medical journals, studies, and lab tests to make a medical necessity determination,” testified Liza Thantranon, Regional Health Counsel at Legal Services of Northern California.

According to Levine’s office, 60% of IMRs have resulted in patients receiving the service they were initially refused, while only 28% of State Fair Hearings have done so.

Under the bill, Medi-Cal recipients will be able to contest rejections, delays, or modifications of medical services through an IMR process starting Jan 1st, 2023. Patients will be able to appeal contested medical decisions up to 6 months after they receive the provider’s decision.

If enrolled in Medi-Cal managed care, the patient must first appeal directly to the plan. If the plan doesn’t respond within 30 days, or if the Director of the Department of Health Care Services (DHCS) waives the requirement to appeal to the health plan due to urgency, then the patient can appeal directly to DHCS. A patient can appeal an IMR decision within 90 days after its issued.

The bill requires DHCS to 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 beneficiaries to access.

It has received zero “no” votes in the legislature so far and has no registered opposed organizations. After unanimously passing the Assembly in Jan. 2022, and the Senate Health Committee last week, it is expected to soon receive a full vote on the Senate floor.