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Molina Medi-Cal Denials

Rejected insurance claim concept with wooden stamp, 3d renderingMolina Healthcare of California is a managed care company headquartered in Long Beach, California. According to the company’s origin story, Molina was founded in 1980 by an emergency room physician who found himself repeatedly dealing with patients using the ER for common illnesses because they could not find doctors who would accept Medi-Cal. Molina began opening clinics to serve low-income individuals in California and became an HMO in 1985.

Molina operated strictly in California until 1997, when it started expanding to other states. Today it offers 19 health plans in over a dozen markets outside of California and continues to serve a large segment of Southern California. In addition to serving Medi-Cal recipients, Molina entered the Medicare market in 2006 and started offering marketplace (Affordable Care Act/Obamacare) plans in 2014.

The company went public in 2023 with an IPO exceeding $100 million.

Unfortunately, Molina’s large footprint in California all but ensures that it will find itself on the wrong end of a government complaint or civil lawsuit accusing it of wrongful claim denials and other bad faith insurance practices. In those situations, the California insurance law attorneys at Gianelli & Morris have the experience and dedication to take them on and make sure they treat their Medi-Cal policyholders right. We’ll fight to see our clients get the medical care they need and the insurance benefits they were promised, along with compensation for any additional harm they suffered, including large punitive damages awards where appropriate.

What Is Medi-Cal?

Medi-Cal is the California version of the federal government’s Medicaid program. It offers no-cost and low-cost health coverage to eligible people who live in California. Medi-Cal is overseen at the state level by the Department of Health Care Services (DHCS), with most individual cases managed at the local county level. Both children and adults may be eligible for Medi-Cal, which is a needs-based program open to people with low income or who are pregnant, blind or disabled. Persons over 65 years old may also qualify for Medi-Cal without regard to income. Since January 1, 2024, Medi-Cal also serves eligible persons without regard to immigration status.

Medi-Cal Services Offered by Molina

Molina Healthcare of California operates in five counties in Southern California: Los Angeles, Riverside, Sacramento, San Bernardino, and San Diego counties. Molina contracts with Health Net to provide services in Los Angeles County.

Molina offers a wide variety of general and specialized services, including:

  • Transportation
  • Nurse advice line
  • Women’s health care services
  • Health management
  • Long term services and supports
  • Mental health
  • Drugs
  • Vision
  • Dental
  • CalAIM

Molina’s HMO-Based Medi-Cal Model

Molina serves Medi-Cal recipients through an HMO model. HMO stands for Health Maintenance Organization. An HMO is a particular type of health insurance plan. HMO policyholders in general are limited to only seeing doctors within the HMO network; out-of-network treatment is usually only covered in an emergency. In contrast, a Preferred Provider Organization, or PPO, allows you to seek care either within or outside the PPO network. The coverage and benefits are greater for in-network care, but out-of-network services are generally not excluded.

HMOs are built to keep costs down for the insurer. One of the ways they do this is by having your primary care physician (PCP) act as a gatekeeper. All of your care flows through and from this doctor, so you cannot seek a specialist or other care without first getting a referral from your PCP. Of course, you would expect your PCP to have your best interests at heart, but they are contracted with the HMO and obligated by the HMO to consider cost-containment even when making medical decisions like which procedure to recommend, which drug to prescribe, or whether to approve a referral to a specialist.

Another concept to be aware of when signing up with Molina is the IPA, or Independent Physician Association. An IPA is a business entity created and owned by a group of doctors or physician practices. IPAs are formed to lower overhead for the constituent medical practices. IPAs are also able to contract with HMOs and managed care organizations and negotiate favorable rates because as a group they have more bargaining power than individual medical practices do.

Molina, Medi-Cal and Managed Care

Most people under Medi-Cal are required to participate in a managed care plan. Similar to the way HMOs operate, under managed care, you choose or are assigned a primary care physician (PCP) who is in charge of coordinating your care, including referrals to specialists. Many services require prior approval from Medi-Cal for individuals under managed care. HMOs and other health plans also typically require prior authorization for a long list of services and procedures. This is another way health plans like Molina work to keep costs down by considering the cost of care and not just the health benefit to the patient.

Medi-Cal Bad Faith Insurance Claim Denials Hurt Our Most Vulnerable Residents

Medicaid and Medi-Cal exist for the very purpose of ensuring that those among us who are most in need of healthcare coverage and can least afford it will receive adequate and appropriate care. When insurance companies deny Medi-Cal claims based on improper motives or pretexts to avoid paying for necessary care, they create a tragedy for our most vulnerable neighbors. Molina is no stranger to litigation and has been embroiled in numerous lawsuits across the country. In one case, for example, a patient with life-threatening COVID-19 complications transferred to an out-of-network facility where coverage for his care was partially denied despite him being told it would be fully covered, initially sticking him with over half a million dollars in hospital bills.

Stories like these are tragic no matter who they happen to. People receiving Medi-Cal, however, are lawfully entitled to care that should not be denied by insurance companies seeking to put an interest in profits ahead of the people they are charged with serving. Gianelli & Morris represents all insurance policyholders throughout California and makes sure their health plan treats them fairly. To discuss a wrongful denial of your insurance claim and what we can do about it, call Gianelli & Morris at 213-489-1600 for a free consultation with our compassionate and dedicated California insurance lawyers.

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