In a victory for patients and physicians, the California Supreme Court says a legal challenge that looks to hold the state accountable for taking no more than 45 days to decide whether an individual is eligible for the state’s Medicaid program, Medi-Cal, can go forward.

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The ruling from the state’s high court overturns an appellate court decision in the case, Rivera et al. v. Kent et al., that said that the 45-day standard set by state and federal statutes and regulations was “merely a target, not an absolute requirement.”

The state Supreme Court decision is a win, too, for the California Medical Association (CMA) and the Litigation Center of the American Medical Association and State Medical Societies. The CMA filed an amicus brief, which the AMA joined, asking the high court to overturn the lower court decision.

The brief tells the California Supreme Court that not requiring the state to determine Medi-Cal eligibility in a timely way would:

  • Significantly harm the health of the state’s neediest and most vulnerable patients who wouldn’t seek preventive care or would delay care and not seek treatment until the condition worsened.
  • Adversely impact how physician practices could serve patients with pending applications because until an application is approved, there is no guarantee physicians will receive payment for the care they provide and it creates a situation where the application could be approved after the time limit to submit for reimbursement has passed.
  • Potentially influence how courts in California and other states determine important issues involving Medicaid policy.

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“Medi-Cal applicants require timely eligibility determinations to access comprehensive medical care and avoid the tragic consequences of delay,” the AMA Litigation Center and CMA brief states. “Moreover, physicians who treat Medi-Cal patients struggle within the administrative confines of the program and take on considerable financial risk to provide care to patients whose applications are pending. It is incumbent on the courts to ensure that the state’s promise of coverage is meaningful for the nearly one in three Californians who depend on Medi-Cal to provide access to critical medical care.”

Find out more about the cases in which the AMA Litigation Center is providing assistance and learn about the Litigation Center’s case-selection criteria.

Medicaid access key during pandemic

More than 12 million Californians—or more than 25% of the total population and more than 40% of the state’s children—depend on Medicaid for care. Nationwide, Medicaid provides care for 64 million individuals, which is roughly one in five Americans.

As California and the nation face the COVID-19 pandemic and a financial crisis, “never in our lifetimes has timely access to affordable healthcare been more important than now,” the AMA Litigation Center brief explains.

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“Many individuals become eligible for Medi-Cal because of a job loss that results in reduced income and loss of employer-based coverage. We are experiencing this dynamic during the COVID-19 pandemic, as many individuals are losing employer-based health coverage and turning to Medi-Cal,” the brief says. “Without Medi-Cal, these individuals would likely be uninsured, with no regular source of health care and they would avoid seeking necessary health care treatment, which results in poor health outcomes.”

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