Backlogs in California’s Medicaid Drug Program Ease, but Problems Persist

SACRAMENTO, Calif. — The contractor working California’s new Medicaid prescription drug program has addressed shortfalls that earlier this yr left thousands of enrollees without critical medications, some languishing on maintain for hours as they sought assist, state officers instructed lawmakers Thursday. 

However docs and well being care clinics say that some sufferers are nonetheless struggling and that the state and its contractor, Magellan Health, have far more to do.  

Michelle Baass, director of the California Division of Well being Care Companies, which administers the state’s Medicaid program, acknowledged the implementation challenges at a legislative finances listening to Thursday. She mentioned the state intends to carry Magellan accountable for its “poor efficiency” below its contract and anticipates withholding roughly two-thirds of its January fee. However she didn’t disclose precisely how a lot that will quantity to. 

“Magellan is addressing the decision middle and prior authorization challenges with a surge of recent hiring,” Baass mentioned. “Name wait instances have dramatically lowered.”

The state launched its new drug program, generally known as Medi-Cal Rx, on Jan. 1, when Magellan took over administering protection for California’s roughly 14 million Medi-Cal sufferers, most of whom beforehand obtained their drugs by about two dozen managed-care plans. Medi-Cal is California’s Medicaid medical health insurance program for low-income individuals. 

The transition was alleged to be seamless. However some sufferers have been instructed that the prior authorizations that they had acquired for his or her drugs have been not legitimate, they usually have been left with out their medication for days or even weeks whereas they appealed. Others merely gave up making an attempt to get assist after ready for as much as eight hours on Magellan’s name middle telephone line.

Docs and pharmacists mentioned a few of their sufferers skilled delays getting lifesaving drugs comparable to antibiotics or medication used to stop seizures or blood clots. 

Though some suppliers say the delays and wait instances have improved, a few of their sufferers are nonetheless having issues. 

“Perhaps enhancements are to return sooner or later,” mentioned Elizabeth Oseguera, affiliate director of coverage on the California Major Care Affiliation, which represents greater than 1,300 neighborhood well being facilities. “However at this second in time, it’s a problem, for not solely the employees, however the sufferers who’re having a lot problem in accessing their drugs.” 

Well being clinic sufferers are nonetheless struggling to get some medication, Oseguera mentioned, in addition to specialty medical provides comparable to needles utilized by transgender sufferers for hormone injections. When Magellan rejects prescriptions, clinics attempt to discover an alternate drug — a guessing sport as a result of neither the state nor Magellan has supplied an inventory of lined medication and provides that features key particulars comparable to authorized producers and doses, Oseguera mentioned. 

Magellan mentioned it has made “vital progress” however that “work is on-going and enhancements will proceed,” in response to a ready assertion that was not attributed to an organization official. 

“Magellan and DHCS are dedicated to making sure Medi-Cal beneficiaries obtain the prescribed drugs they want after they want them,” the assertion mentioned. 

KHN reported on the issues plaguing the brand new prescription drug program on Feb. 9. On Thursday, officers with the Division of Well being Care Companies mentioned Magellan had cleared its backlog of prior authorizations by Feb. 11 and has been reviewing all prior authorization requests inside 24 hours since Feb. 14.

Between Jan. 1 and Feb. 18, Magellan acquired greater than 130,000 requests for prior authorizations, that are required for drugs that docs contemplate medically mandatory however are typically not on the state’s authorized drug listing. 

However Magellan couldn’t reply to requests rapidly, partly as a result of it was understaffed and unprepared, state officers instructed lawmakers in an Meeting finances listening to Feb. 7. Numerous its name middle employees have been sickened in the course of the omicron surge, and the corporate didn’t get all the information it wanted from managed-care plans — which slowed the corporate’s opinions of the requests.

In response, the state took a number of emergency actions — comparable to eradicating prior authorization necessities for many drugs and giving pharmacists codes to override prescription denials — to scale back the backlog. The state additionally briefly supplied staffers to spice up the depleted workforce of the contractor, which reported 100 of its 220 staff absent in the course of the first two weeks of the yr. 

These steps have “dramatically lowered” name wait instances, and Magellan was answering calls inside 45 seconds on common as of Feb. 22, Baass instructed lawmakers Thursday. By the top of February, Magellan expects to have added greater than 120 staffers to its customer support middle and greater than 72 new hires to the prior authorization desk, she mentioned.

Baass mentioned there may be now a course of that enrollees and docs can observe to get assist if they’ve issues getting drugs. Magellan can also be establishing a telephone line for sure sufferers with advanced well being wants. 

Though the non permanent waivers and override codes have helped many Californians get their drugs, physicians fear that such fixes are Band-Aids.

“It’s a brief repair that’s useful proper now,” Oseguera mentioned. “As soon as these waivers are lifted, lots of our sufferers could not be capable to entry their drugs once more.” 

State Sen. Richard Pan (D-Sacramento) warned Medi-Cal officers to proceed cautiously. In July, the state is not anticipated to robotically settle for prior authorizations that sufferers had obtained by their managed-care plans. 

“It’s essential that if for some purpose there isn’t enough employees in place or different causes, then we have to sluggish the transition,” Pan mentioned on the listening to. “In order that we don’t depart sufferers hanging like what we noticed at first of January.” 

This story was produced by KHN, which publishes California Healthline, an editorially unbiased service of the California Health Care Foundation.

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