From a duffel bag in Victor Valero’s hospital bed, a large plush Pikachu protrudes overhead.
“That’s my dialysis partner,” he said. “accompany me.”
Valero’s kidneys failed in 2018 — the result of diabetes, he said. Three mornings a week, he’s chained to a blood-washing machine. His diabetes also left him blind in his left eye, and he needed heart surgery last year.
why this matters
To maintain coverage, some Medi-Cal members are required to pay their entire monthly income—except $35. Advocates and state officials are divided over whether to allow some people to be asked to pay this “cost-sharing” during a public health emergency.
Valero, 47, said he struggled to keep a job as his health declined. He became homeless, running back and forth between hotels. In July 2021, Valero moved into Parker Anaheim Medical Center, a nursing facility that keeps him stable and closer to his children and the dialysis center he relies on.
Then in October 2021, Valero found out he had to pay for the health care benefits he received through Medi-Cal, the state-run health insurance plan. Price: Pretty much everything he earns every month.
“I was angry. I was helpless,” he said.
Medi-Cal members who end up receiving 30 days or more of long-term care may be required to pay a portion of the cost of the care they receive. This “cost share” could mean they would lose their entire paycheck except for the $35 per month “personal needs allowance”. However, those who end up in long-term care, perhaps after a serious illness or injury, may still have other financial obligations, such as car payments or storage fees, so advocates have long argued that their $35 a month left with is unacceptable.
“The only word I can think of is piddly,” said Alicia Emanuel, a lawyer for the company. National Health Law Program, advocating for federal and state health care issues. “There’s a real impact on people on low incomes.”
lawyer to talk to Xinyuan Said that increasing fee requirements for Medi-Cal members during a pandemic violates federal regulations because state Medicaid programs do not allow certain “negative actions” against Medi-Cal members during a public health emergency.
State officials disagree.in a statement new resources, A spokesman for the Department of Health Care Services wrote that while in many cases, cost-sharing increases are not currently permitted, with the exception of “long-term care.”
Despite this stance, when legal aid groups apply to administrative law judges for hearings to handle individual cases, the department has stepped in to remove fee shares. The department would not explain why actions were taken to eliminate cost shares in some individual cases.
Rather than addressing each case individually, advocates want the state to update its guidance to halt such transitions during the pandemic. public health emergencywhich is currently scheduled to end this summer.
“It’s maddening that policy issues can’t be addressed more broadly,” said Jack Daly, the policy director. San Diego Legal Aid Society. “If there is a compelling case for addressing these individual cases, why does the state’s policy not have a compelling case for acknowledging the harm that may have been caused?”
response from new resources, A spokesperson for the Centers for Medicare and Medicaid Services wrote that the agency is aware of California’s problems: “At this time, CMS is assessing whether the controversial practice is inappropriate, and we will continue to work with the state on this issue. .”
Advocates like Daly don’t know how many people are newly forced to pay a portion of the bill during the pandemic, or what the consequences are for those who don’t seek legal help.
Xinyuan The state has been asked to provide these figures and is awaiting further information. also, Xinyuan Ask how many cases the state has before an administrative law judge. The agency did not track the information and referred the issue to another department, the spokesman said.
Courtney Brown said her mother received long-term care in August 2020 for a neurological condition. Since she was unable to make her own medical decisions, Brown became her mother’s authorized representative and took over her Medi-Cal. A few months later, she saw her mother’s cost-sharing approach close to $1,300 — nearly all of her monthly income — but the County of San Diego didn’t notify Brown of the change.
“It’s a punitive system that doesn’t even operate by its own rules,” she said. “If you don’t order one A generation, they’re ready to drop your case, but it seems they can do it against their own guidelines. “
in a statement new resources, County officials said they were unaware of the notification issue.
Brown decided not to pay and eventually got in touch with San Diego Legal Aid. San Diego County eliminated cost-sharing after the state requested it. Although Brown’s case is settled, she wonders what happens to those who were charged a portion of the fee and didn’t back down.
“I don’t understand how they expect anyone to pass all basketball games,” she said.
Covered by Medicaid Medi-Cal about one third The state’s population includes millions of low-income, elderly, pregnant, blind or disabled people.
Valero only discovered his share of the fee through a conversation with Parker Anaheim—his notices were sent to an old address. He said he paid for several months before realizing it was not sustainable. The $35 he has left over a month is not enough to cover his living expenses, such as phone bills, child support for his two children, or any extra food he buys. His savings are dwindling.
“I’m really helpless because I can’t figure this out…I’m even thinking [of] Moving back to Illinois and living with my dad means keeping my kids here,” he said. “It’s really frustrating. “
During the ordeal, Valero sought the help of lawyer Joan Chang. Community Legal Aid SoCalChang said her organization has dealt with at least three cost cases, but stressed that the consequences for her clients were devastating and the actual number of people affected by the issue was unclear. (Daly said San Diego Legal Aid has handled three or four other cases.)
“Sadly, we got calls from people who knew who we were,” Chang said. “There are a lot of other … people across the state who are going through this that are not reaching out.”
Chang said one client she organized left long-term care to avoid paying a share of the cost and ended up in the hospital. “Some people put themselves at risk,” she said. “A lot of people don’t know how to defend themselves.”
The state stepped in to remove Valero’s share of fees after Zhang filed for a hearing before a judge. Failure to pay could lead to eviction, and Valero said he could be hospitalized if he is forced to move out. He’s grateful he found help.
“I was told ‘no’ many times,” Valero said. “I might be on the street.”