Medicaid Patients and Doctors Are Seeking a Cure for Denver Health's Managed Care

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Several things can trigger the passive enrollment, including if a Denver patient doesn't expressly opt out of the Denver Health plan when his or her Medicaid benefit comes up for annual renewal. It can also occur when a patient moves to a new Denver address or when a Medicaid baby is born in Denver, which is what happened most recently to the Presleys.

The family first started going to South Federal Family Practice in 2009, soon after Presley became pregnant with Isabella. At the time, they were living in Wheat Ridge. Her husband had recently lost his job, and Presley's income as a hairdresser wasn't enough to pay for health insurance. So she got on Medicaid, the government insurance program that covers low-income families and people with disabilities. South Federal Family Practice has long served Medicaid patients alongside clients with private insurance, and Presley fell in love with the providers there.

"Everyone in that office is so kind and so caring and so helpful," she says.

Six weeks after Isabella was born, however, the two of them lost their Medicaid coverage: Since Presley's husband was working again and she'd gone back to the hair salon, the family made too much money to qualify. So they went without any insurance until Presley found out she was pregnant with Parker, making her eligible for Medicaid again. She returned to South Federal Family Practice for her prenatal care, and when she was seven months along, her husband lost his job again, which allowed Isabella to get back on Medicaid, too.

By the time Parker was born, in June, the Presleys had moved from Wheat Ridge to Denver, just blocks from South Federal Family Practice. But Presley soon found out that she couldn't take her son there with the rest of the family. Rather than being enrolled in Colorado's regular Medicaid plan, which allows recipients to see any doctor who accepts Medicaid, he was automatically enrolled in Denver Health's plan. That meant Parker would only be allowed to see Denver Health doctors at Denver Health clinics.

"I want to see this doctor," Presley says of Dr. Roy Durbin, the founder of South Federal Family Practice. "He has a history with my family and my children. I'm a little old-school, where I want one doctor."

Presley came home from the hospital to a pile of paperwork from Health Colorado, the outside company that the state pays to enroll Medicaid recipients in the various plans available to them. The paperwork instructed her to call if she wanted to opt Parker out of Denver Health's plan, which she did. She also got paperwork informing her that Isabella would be switched to Denver Health, as well. So she called Health Colorado and told them she didn't want Isabella on Denver Health's plan, either.

"But I keep getting paperwork saying she's on Denver Health again," Presley says, exasperated. She pulls out the most recent letter she received; attached is a Denver Health Medicaid Choice insurance card with Isabella's name on it. "Obviously, what I did didn't work."

Presley is one of many patients who get caught in what some local doctors say is a frustrating, time-consuming and mysterious system that automatically and repeatedly funnels all Denver Medicaid recipients into the Denver Health network -- often without patients realizing it until they show up for their next appointment, only to be told that Medicaid won't pay for them to see their non-Denver Health doctor anymore.

"I'm not bashing Denver Health," says Durbin. "We need Denver Health, and we need the doctors in Denver Health. But patients should have the freedom to go where they want, at the time that they need that particular care."

Dr. PJ Parmar feels the same way. Parmar has a private practice in Aurora where he serves refugees, most of whom are on Medicaid. In June he started a petition on calling for Colorado to eliminate "managed care Medicaid," as he calls it, or Medicaid plans that limit patients to a certain set of doctors. The petition has garnered more than 2,000 signatures and the attention of state senator Irene Aguilar, who is a former Denver Health doctor and a current member of Denver Health's board of directors.

Aguilar's attention has, in turn, prodded state officials to begin taking steps toward dismantling passive enrollment, something longstanding providers say they've been requesting for years. As with most institutional changes, however, the fix won't come quickly. And furthermore, Parmar and other doctors believe that the proposed solutions don't go far enough.

"That's a first step," Parmar says. Getting rid of passive enrollment, he says, "just stops new people from being put into this, just filling up the bucket. But it has nothing to do with the fact that the bucket was already overflowing."
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Melanie Asmar is a staff writer for Westword. She joined the paper in 2009 and has won awards for her stories about education, immigration and epic legal battles. Got a tip? She'd love to hear it.
Contact: Melanie Asmar