For some new Medicaid clients, delays getting care, prescriptions

Margaret Hagins felt like crying when she learned she’d qualify for Medicaid under the federal health law. Even now, four months later, she chokes up when she talks about it. Having coverage means she no longer has to figure out how to pay for enough pills to keep her bipolar disorder in control, or choose between buying food, paying bills or filling her prescriptions.

In theory, Hagins, like thousands of other Connecticut residents, got Medicaid coverage Jan. 1, the date the program expanded as part of the law commonly known as Obamacare. But for close to six weeks, she said she couldn’t use it or get a prescription paid for because she didn’t have a Medicaid card.

She’s hardly alone. State Healthcare Advocate Victoria Veltri said problems with Medicaid are now the most common reason people call her office. Often, the calls come from people like Hagins who qualified for the newly expanded part of Medicaid, known as HUSKY D, but don’t have an ID card and are wondering if they can seek care yet.

People who are deemed eligible for the program receive a letter to use as proof of coverage until their Medicaid cards arrive, but some, including Hagins, have found that some pharmacies and doctors won’t accept it.

Veltri noted that some doctors and pharmacists might be worried about providing care without any guarantee of when they’ll be paid.

“Right or wrong, it is what it is,” she said. “It feels to me like something has to be done … What is plan B for these folks?”

System isn’t fully automated

When someone qualifies for Medicaid, his or her information must be entered into the state Department of Social Services’ eligibility management system. That allows the person’s Medicaid ID card to be sent out, and it enters the person into the system that health care providers check to verify coverage.

According to DSS, that data entry occurs within four days in roughly 73 percent of new Medicaid cases. But in more than a quarter of the cases, it takes longer.

Close to 73,000 people have signed up for Medicaid since Oct. 1.

To improve things, the department is temporarily reassigning 15 workers to address problem cases.

The 15 workers had been working on plans for a new system to replace the department’s outdated eligibility management system — which is itself part of the reason people like Hagins have had trouble getting coverage set up.

When people apply for coverage online or by telephone through Access Health CT, the state’s health insurance exchange, the system quickly determines if they qualify for Medicaid. Applicants then receive the paper notice to use as proof of coverage.

But the Access Health system isn’t connected to the DSS eligibility management system. So applicants’ information must be sent as PDFs from Access Health to a state contractor, Xerox State Healthcare, where workers manually enter it into the DSS system.

(By contrast, the process for enrolling someone in private insurance through Access Health is entirely automated.)

In the roughly 27 percent of cases that don’t make it into the DSS system within four days, the major reason for the delays is complications with documents coming from Access Health, DSS spokesman David Dearborn said. Some require a DSS worker to intervene to resolve an issue, such as if the information from the Medicaid application is inconsistent with information on the person or household members already in the DSS system, or if the person is enrolled in other DSS programs. There have also been intermittent issues with the Access Health system, which Xerox workers sometimes have to use to look up missing information, he said.

Dearborn said the department is preparing a new notice for providers to explain that they will get paid for seeing people with the proof-of-coverage letters. The DSS pharmacy unit is also reaching out to pharmacies individually to ask them to dispense medication to new Medicaid clients.

Dearborn said the department has expedited the data entry in cases when a person urgently needed a medication or medical services and was having trouble getting them. Veltri’s office has been able to get clients’ cases prioritized, too, but she said there needs to be a more systemic solution.

“We’re fixing them one by one,” she said.

Food, bills or medicine                          

Hagins’ wait to use her coverage followed years of struggling to get the care she needed.

She’d had coverage through her employer until losing her job three years ago. She eventually began working part-time at the Wilson-Gray YMCA in Hartford. Hagins, 53, said she makes a little more than minimum wage and couldn’t afford insurance.

Her psychiatrist agreed to see her for free. But Hagins had to figure out how to pay for the medication she needed to stay stable and do her job.

“It was a choice between medication, food or bills, and nine times out of 10 I chose medication,” said Hagins, who lives in East Hartford.

Sometimes she could save $75 to buy 30 of the pills she takes for bipolar disorder. Other times she’d buy five or 10 pills, just enough to stave off problems.

“I just couldn’t let myself fall back into the depression or just not caring,” she said. “I’ve come too far, and I knew what it took for me to be stable, so I did what I had to do in order to keep my medication.”

At times things seem to line up for her, like when her doctor gave her drug samples for her ulcerative colitis, or when Hartford Hospital’s mobile mammogram clinic parked down the street from Hagins’ job and she ran over to get a screening.

But other times, nothing seemed to work. She was off her medications entirely last fall and ended up in the emergency room.

A new option

That was right around when the enrollment period for coverage under Obamacare began. Hagins said she’d been planning to look into the state’s health insurance exchange when a woman named Alexa Gray came to the YMCA, where she works, and asked if anyone needed coverage.

“I had heard about the program, but I didn’t know that it was so accessible,” Hagins said.

Gray, who works at the Hartford-based Community Renewal Team, is one of more than 300 people trained to help state residents sign up for coverage. She helped Hagins enroll that day.

That was October. It was great, Hagins said. “But still, I had no medication.”

January came and went. All Hagins had to prove she had Medicaid was the letter.

“The pharmacy would not accept the letter,” she said. “Because my name was not in the system as active.”

Margherita Giuliano, executive vice president of the Connecticut Pharmacists Association, said DSS explained to pharmacists that people would be coming in with a letter saying they qualified for HUSKY, and that it would take about 10 days for their information to be entered into the enrollment verification system.

Giuliano said she wasn’t aware of any association members that didn’t accept the letters as proof of coverage. She noted, though, that doing so meant that pharmacists would be dispensing medication without payment.

“If it’s becoming financially challenging to the pharmacy, I guess it’s a decision that they would make,” she said, adding, “Our pharmacists try to accommodate patients.”

Waiting

Hagins called DSS, but she became frustrated by the wait times on the phone line.

At one point, she got help from a woman who works at DSS and happened to call the YMCA. She told Hagins her information was pending.

Then, two weeks ago, a month and a half after the coverage was to have started, Hagins learned she was in the DSS system. When the DSS worker told her she was in the system and could call her pharmacy, Hagins said she wanted to cry.

Her HUSKY card arrived a few days later.

“It’s a relief,” she said. “It really is a lot of pressure off my shoulders.”

She got her medication and made appointments with doctors. She now makes a point of telling other people about their options if they don’t have coverage.

Hagins said being without insurance made her more sensitive to what other people go through. She wonders how people who are older or struggling with mental illness and can’t afford medications get by.

“It was scary,” she said. “But I’m a better person for it, I guess. I hope.”