Medi-Cal Vs Private Insurance: Better Patient Treatment?

There is a growing debate about whether patients are better treated with private insurance or public insurance programs such as Medi-Cal, California's version of Medicaid. While private insurance is often associated with better treatment and more comprehensive coverage, there are instances where individuals with serious mental illnesses or specific conditions may benefit from switching to public insurance. This is particularly evident in California, where residents with mental health issues are opting for taxpayer-funded treatment through Medi-Cal instead of relying on their private insurance plans. This trend raises questions about the responsibilities of private insurance companies and the state in ensuring adequate treatment for individuals with serious mental illnesses. Additionally, studies suggest that cancer patients with Medi-Cal have lower survival rates and are less likely to receive recommended treatments compared to those with private insurance. However, it's important to note that Medi-Cal can be used as secondary insurance to cover expenses not included in primary health insurance.

Cancer patients with Medi-Cal are less likely to receive recommended treatment

Cancer patients with Medi-Cal, California's version of Medicaid, are less likely to receive recommended treatment and have lower survival rates than patients with other types of insurance. This disparity is particularly concerning given that cancer is the second leading cause of death in California, with an estimated 189,000 new cases and 61,000 deaths expected each year.

A study by UC Davis researchers found that compared to patients with private insurance, cancer patients with Medi-Cal were less likely to be diagnosed at an early stage, receive recommended treatments, and survive five years after diagnosis. For example, 27% of Medi-Cal patients with breast cancer were diagnosed at a late stage, compared to 12% of those with private insurance. Similarly, 52% of Medi-Cal patients received the recommended treatment of breast-conserving surgery, while 60% of privately insured patients did.

The reasons for these disparities are not fully understood. One possible explanation is that Medi-Cal patients may drop in and out of the system, missing preventive screenings that could detect cancers earlier. Additionally, audits and studies have shown that some Medi-Cal patients face difficulties in accessing doctors and specialists, which may be due to lower reimbursement rates that discourage providers from accepting Medi-Cal patients.

To address these issues, California passed a law that requires Medi-Cal insurance plans to make a good-faith effort to contract with cancer centers recognized by the National Cancer Institute or other qualifying cancer centers. This law aims to improve access to specialized cancer treatment for low-income patients, but it has been criticized for not going far enough to address the disparities in cancer care.

While Medi-Cal offers crucial support for low-income individuals, the disparities in cancer care highlight the need for continued improvements to ensure that all Californians have equitable access to timely and effective treatment.

Californians with mental illnesses are dropping private insurance for Medi-Cal

There is a growing trend among Californians with serious mental illnesses who are dropping their private insurance in favour of Medi-Cal, a public system for low-income residents. This is due to the fact that private insurance often does not cover the intensive mental health services that are available through Medi-Cal.

The Problem with Private Insurance

Private insurance companies are not legally required to offer intensive mental health services, which can include case management and help with transportation to treatment. This has led to a situation where people with serious mental illnesses are not getting the treatment they need and are instead turning to the public system for help.

The Benefits of Medi-Cal

Medi-Cal, California's Medicaid program, offers low-cost or free health insurance to eligible residents with limited incomes. It provides a range of mental health services, including individual or group therapies, medication support, day rehabilitation, and crisis intervention. These services are often more intensive and provide more support than what is covered by private insurance.

The Challenges of Switching to Medi-Cal

However, switching to Medi-Cal is not always an easy decision. Families with children under 18 may need to consider leaving their jobs or relinquishing custody to meet the strict income eligibility requirements. Additionally, dropping private insurance may mean giving up relationships with trusted providers and specialists. There may also be longer wait times for certain treatments with Medi-Cal.

The Way Forward

To address this issue, some California agencies have begun partnering with commercial insurance plans to provide intensive mental health services to children with private insurance. There are also legislative efforts, such as San Francisco Democratic Sen. Scott Wiener's SB 855, which would require insurers to cover all medically necessary treatments for mental health and substance use disorders.

Patients with private insurance are treated more fairly

Private insurance is also associated with a reduced risk of delayed diagnosis, which can improve the chances of surviving cancer. Patients with private insurance are more likely to receive screening services and are more likely to receive them in a timely manner. They are also less likely to experience a delay in starting treatment and are more likely to receive effective drug therapies.

In addition, private insurance provides access to a regular source of care, which is important for managing chronic conditions. It also facilitates access to hospitals that perform angiography and revascularization procedures, which can improve patient outcomes in the event of a heart attack.

Furthermore, patients with private insurance are less likely to experience adverse medical events due to negligence and are more likely to receive intensive therapeutic behavioural programs and wrap-around services.

Overall, patients with private insurance have better access to health care services and are treated more fairly compared to those with other types of insurance.

Medi-Cal may be used as secondary insurance to pay for expenses that primary insurance doesn't cover

In California, Medi-Cal is a Medicaid program that provides health coverage to eligible residents with limited incomes. It can be used as secondary insurance to pay for expenses that primary insurance doesn't cover. This includes medical supplies, such as diapers and G-tube formula, and durable medical equipment (DME).

If a child has multiple insurance plans, including private insurance, Medi-Cal is the payer of last resort. The child's private insurance bears primary responsibility for healthcare coverage. Any other secondary private insurance must be billed before Medi-Cal will cover the service. The provider must contract with both the private insurance and the Medi-Cal managed care plan.

If there are remaining costs or copayments after the primary insurance pays its share, Medi-Cal can be billed for the amount not covered by the primary insurance, up to the Medi-Cal reimbursable rate. This means that if a provider charges a certain rate for a therapy, and the private insurance pays its portion, then Medi-Cal will pay the remainder of the bill up to the contracted Medi-Cal rate. However, the patient will still be responsible for any services and procedures that are not covered by Medi-Cal.

To use Medi-Cal to cover copayments and deductibles, the patient must first ensure that their physician, facility, or service accepts their primary insurance. Then, they can ask if the provider contracts with their Medi-Cal managed care plan. If they do, the provider can bill the patient's primary insurance before billing the amount not covered to Medi-Cal.

In some cases, a treatment authorization request (TAR) may be required before receiving certain medical services from Medi-Cal. It is important to ask the provider whether a TAR is needed and how long the authorization process will take. The provider can use a TAR form to request authorization and receive payment for services like physical therapy, DME, and speech therapy.

For services or supplies that aren't completely covered by primary insurance, a written denial of coverage from the primary insurer is necessary, along with a prescription or order from a doctor indicating that the service, medication, or supplies are medically necessary. This process also applies to obtaining consumables like incontinence supplies for children over the age of three.

Medi-Cal offers free or low-cost health insurance to eligible Californian residents with limited incomes

Medi-Cal is California's Medicaid health care program. It offers free or low-cost health insurance to eligible Californian residents with limited incomes. This includes comprehensive health coverage for children and families, as well as pregnancy coverage. In addition, Medi-Cal provides coverage for adults without children, seniors, and people with disabilities.

To be eligible for Medi-Cal, individuals must meet certain income requirements. For adults, income must be up to 138% of the Federal Poverty Level (FPL), while for children, it can be up to 266% FPL. Additionally, residents in skilled nursing or intermediate care homes, parents or caretakers of disadvantaged children under 21, people with refugee status, and those diagnosed with breast or cervical cancer may also qualify.

Medi-Cal can be used as secondary insurance to pay for expenses not covered by primary health insurance. It can also fund medical supplies and durable medical equipment. In some cases, Medi-Cal may be the payer of last resort, covering remaining costs after primary insurance has paid its share.

In recent years, there has been a debate about the quality of mental health treatment provided by private insurance compared to Medi-Cal. Some Californians with serious mental illnesses have chosen to drop their private insurance in favour of taxpayer-funded treatment through Medi-Cal. This is due to the intensive mental health services and case management offered by Medi-Cal that may not be available through commercial plans. However, it is important to note that wait times and access to specialists may be longer with Medi-Cal.

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