Details of Pilot Medi-Cal Plan Explained

The controversy that has surrounded the start of the state’s cost-cutting pilot program to provide care for San Diego’s 160,000 Medi-Cal beneficiaries was in little evidence Wednesday at a hearing on the program’s regulations.

Only four people questioned representatives of the California Medical Assistance Commission. Spokesmen for a health maintenance organization (HMO), a wheelchair service and a legal aid service representing Medi-Cal recipients asked for technical clarifications on the wording of the plan’s provisions. One Medi-Cal recipient asked for a general explanation of the program, which now is to begin in August.

The experimental “Expanded Choice” program initially was to start April 1, but the deadline recently was pushed back for a second time.

Regulations outlining the options of beneficiaries and responsibilities of HMOs will probably be adopted by the commission at its Feb. 4 meeting, said Patsy Crawford, acting general counsel for the commission.

“Expanded Choice” is a new program in which the state will pay HMOs a set monthly fee for each Medi-Cal beneficiary’s medical needs rather than reimburse doctors, pharmacists, hospitals and other health providers as services are rendered.

The state Department of Health Services will send notices to San Diego beneficiaries by May 1 briefly explaining the program and asking them to enroll in an HMO serving their area. Eleven HMOs have qualified for the program.

Beneficiaries then have 90 days--until Aug. 1--to select an organization. If a beneficiary does not express a choice, he will be assigned to an HMO, said Lynda Martland, chief of the state office of Capitated Health Systems, a division of the department.

Also on May 1, a private company selected by the state to act as an information center for the program will open in San Diego, answering all inquiries from beneficiaries and sponsoring outreach programs for community groups. A company will be selected by mid-February to act as the enrollment contractor, Martland said.

The program will last at least three years, Martland said, and the department will review and analyze the plan’s progress after 18 months.

Critics of the program charge that it will sever longstanding doctor-patient relationships and reduce the quality of care for Medi-Cal beneficiaries. Spokesmen for the commission, however, say the plan tries to keep disruption of beneficiaries’ treatment to a minimum.

In San Diego County, annual savings could reach $8 million, officials say. Medi-Cal otherwise would expect to spend $160 million next year in the county.

About 15% of local Medi-Cal recipients with serious health problems--the mentally ill, severely handicapped children and others under continuous treatment--will not be required to join HMOs, according to Michael Murray, executive director of the Medical Assistance Commission.