Medicaid Reform Consumer Finds Obstacles on Way to Care

First published on CHAIN Reaction, May 1, 2007

David Reid had just made the jump from the banking industry to the one he really loved, music, when he suffered a brain aneurism in Brooklyn 25 years ago. When he arrived at the emergency room at Kings County Hospital, the attending physician took a look at him and, mistaking his stroke for drunkenness, told him to “sober up” and sent him home. Whatever damage might have been averted by early intervention became permanent with the addition of ensuing complications.

The experience impressed upon Reid the importance of a trusting relationship between patient and doctor. When he moved to Florida, Reid began building that relationship with the scores of physicians he needed to give him the care necessary to lead a decent life. In 1998, for example, he needed three operations to remove some clotting. More recently, he needed to be operated on for appendicitis.

“Under Medipass, it was all covered without problems,” he says in a slightly slurred, carefully cadenced speech. “Until last June I was able to see all the specialists I needed and had gotten to know over the years.” Then, last September, Reid received two Medicaid Reform enrollment packets within the space of 3 weeks. Concerned by the instruction bidding him to choose a plan or have one chosen for him by the State, Reid spoke first to his long time Primary Care Physician who advised him to pick Staywell because he was a provider under the plan. In addition, Reid was “sold” on the additional perks described in the enrollment materials, including the over-the-counter benefits it lists.

“Last December I received a letter from AHCA (the Agency for Health Care Administration) telling me about points I had received to redeem products at the pharmacy,” he recalls. “When I went to the pharmacy with the letter, I was told I needed to contact Staywell to redeem the products. I called Staywell, and I was asked to provide a list of what I wanted. I gave it to them. It’s the end of April and I still haven’t received anything.”

Reid couldn’t recall whether the list of products pertained to the Enhanced Benefit Component of Medicaid Reform or the one provided by Staywell. (The confusion between the two types of benefits has been documented on various occasion in Medicaid Reform Consumer roundtables conducted by Florida CHAIN and MRAC, the Medicaid Reform Advocates Coalition).

Not getting the over-the-counter products perks is annoying but the least of Reid’s problems. Under Medipass, his doctor had prescribed Prevacid to manage another one of the “legacies of my stroke, “as he calls them. Staywell does not cover Prevacid nor his second choice option, and the medicine they do cover causes unwanted side effects.

In addition, once signed up in the plan, Reid realized that his neurologist was not a member. His general internist was listed in the plan directory but had since dropped out, as had his long-time eye doctor. When he called Staywell to tell them doctors listed in their directory were not taking him, he was told, “Well, they are supposed to.”

Florida CHAIN contacted ACS, the choice counseling providing company, on Reid’s behalf to see whether he could get assistance in finding a plan that better suits his needs, even after the 90 day deadline. One suggestion given by the field choice counselor referred by the Special Needs Unit was that he appeal the acid reflux medication decision, so Reid called Staywell again.

“When I called about appealing the medication decision, the plan operator was so rude. When I asked to speak to a supervisor to clarify what I needed to send them, I had to threaten to report her to Tallahassee before she transferred the call,” he said. “Since this Reform I can’t tell you how much more stressful my life has become.”

Reid is also rather sour on the Choice Counseling component of Medicaid Reform: “When I called at the beginning of the enrollment process, the operator assured me that ‘everything would remain the same’. Well, nothing has remained the same after reform,” he said. “When I commented to the Special Needs nurse who I thought might help me with the acid reflux medication problem, that it is a strain on the doctor to be administrating Staywell, she asked me if I was getting paid to say so.”

In Reid’s case, Medicaid Reform has not worked on many angles: the managed care plan, whose phone representatives have been rude and ineffective and whose Preferred Drug List does not include the medication he needs, and whose physician directory is outdated; the choice counselors who misinformed him and rather than being responsive to his needs have wondered as to his motives; and the Enhanced Benefit component, since he is still trying to get products he has been entitled to since December.


We are interested in hearing from Medicaid Recipients in Broward County and Duval County. Please contact us by email at medicaidreform@pobox.com.

www.floridamedicaidreform.org