Local health administrators and optometrists are pushing back against a recent change to San Luis Obispo and Santa Barbara counties' managed Medi-Cal plan, CenCal Health, that strips away all coverage of private prescription eyewear in favor of glasses produced by state prison inmates.
- FILE PHOTO BY JAYSON MELLOM
- LABOR BEHIND BARS A change to CenCal Health's vision benefits outsources its eyewear services to inmates in prison work programs.
Passed down by the California Department of Health Care Services (DHCS), effective this year, the plan change impacting 186,000 enrollees has already led to prescription delays and caused local eye care professionals to drop out of CenCal's network, officials said.
Stakeholders fear that it's just the beginning of an exodus that will impact vulnerable communities.
"We immediately told the state this was going to be a problem," said Michael Harris, CenCal Health's director of government and administrative services. "It's dramatically altered the ability of our members, including children, to get eyewear easily. ... It's the opposite of everything you try to do in health care."
For years, CenCal Health's vision plan covered both eye exams and prescription glasses at more than 45 participating optometry offices across the two counties.
Low-income families on CenCal had a variety of options for eye care, Harris said, because local doctors could afford to be a part of its network. And that was because CenCal paid them to provide both the exams and the glasses.
"The providers aren't making a ton of money [on CenCal], so if you give them Medi-Cal rates in two different areas, they feel like they can support us," Harris explained. "The providers supported CenCal by participating; we provided support to the providers by letting them do both parts of the service. We have a very, very large network of providers that makes it really easy for our members to get care."
Any hint of a proposed change to CenCal's vision plan "was not even a blip on our radar screen," Harris said. But late last year, the DHCS "unilaterally" informed the agency that starting Jan. 1, 2020, CenCal would have to use the California Prison Industrial Authority (CalPIA) for all of its eyewear fabrication benefits.
"They just told us this is what we have to do, and they literally turned off our funding," Harris said.
DHCS officials said that CenCal's new plan simply aligns it with the rest of the Medi-Cal plans in the state. CenCal Health was one of two plans in California, along with the Health Plan of San Mateo, that still offered private eyewear benefits. All of the other plans sourced their glasses from the CalPIA, which since 1988 has had an "interagency agreement" with DHCS to fabricate glasses for Medi-Cal members.
"This change ensures that all Medi-Cal beneficiaries have the same benefit, regardless of their county of residence or managed care plan," DHCS spokesperson Carol Sloan told New Times by email.
CalPIA currently has two optical laboratories—one at Valley State Prison near Fresno and another at the California State Prison in Solano—where inmates are paid $1 per hour or less to fulfill prescription eyewear orders for "marketable skills training." The CalPIA's glasses program is its third-highest-profiting enterprise, behind fabrics and license plates, taking in about $6.5 million per year, according to a 2018-19 annual report.
Sloan wrote that the benefits of the CalPIA system to recipients and taxpayers include "real-time utilization control, eligibility check, fraud/abuse reporting and detection; 24/7 secure online ordering, tracking website, and customer services; online approval for replacements; express courier services at no cost to providers or beneficiaries; prevents 'upselling' by providers; and provides inmates with marketable skills training."
But CenCal's Harris contended that the change has only served to upend a successful program, and that his staff has already received an "influx of calls" from local eye care offices reporting three- to four-week wait times for CalPIA orders, as well as a "larger issue" of "lost frames, missing orders, and many redone requests of the glasses ... due to scratches on lenses."
"These delays further damage a system of eye care that was functioning smoothly for literally decades," Harris said.
To cushion the transition, CenCal decided to self-fund its existing eyewear coverage through June 30 with about $700,000 in reserves. The move gave providers some time to transition to CalPIA and it also gave officials time to try to lobby DHCS to reconsider.
But neither a CenCal staff visit to Sacramento nor a strongly worded Aug. 7 letter to DHCS's chief of managed care operations has sparked a course change. In DHCS's response to New Times' questions, the agency said it "is not considering reverting back to allowing the fabrication of lenses to be covered by CenCal Health."
Since CenCal's six-month subsidy lapsed, Harris said that two Santa Barbara County practices have fully terminated their contracts, and about 20 providers across the plan are no longer taking prescription orders.
"If you live in Solvang and a couple years ago you got an eye exam and prescription, you'd just get them at the same provider," Harris said. "Now, if you get an eye exam and you need glasses, you can't get them in Solvang. You have to go find someone who does a prescription."
Doug Major, a SLO County optometrist who's involved in putting on annual vision screenings at elementary schools, told New Times that he's concerned about how low-income families and their children will be able to access eye care in the future. Eye issues require intervention early on to avoid impacts to children's academic progress and quality of life down the road, he said.
"By the time they're already 15, it's too late. It's a diagnosis that could've been made in Head Start," Major said. "It's so easy to do. Compared to all the other costly things, this is the cheapest and easiest, so make it accessible."
Major said he's kept a close eye on the expansion of the CalPIA optical program—which he calls "somebody's pet project"—and doesn't believe it serves Medi-Cal members well or even saves the state money.
"I've seen the rest of the state go down this path. The problem is, we'd be headed down the same path," he said. "Once we lose the network, it's going to be very difficult to get it back. This is something that could be fixed and should be fixed." Δ
Assistant Editor Peter Johnson can be reached at firstname.lastname@example.org.