By Jocelyn Wiener October 30,
2019
Some of
California’s most vulnerable nursing home residents, many of whom have nowhere
else to go, are receiving letters from their health care plans saying they are
no longer eligible for long-term care.
In one
notable example, three dozen nursing home residents in San Luis Obispo County
were informed on the same day that their Medi-Cal managed care plan was cutting
off payment for nursing home care, said Karen Jones, the county’s long-term
care ombudsman.
The
residents included a 68-year-old amputee with diabetes, memory loss and kidney
disease who required dialysis three times a week, and an 82-year-old man with
congestive heart failure and diabetes who wasn’t strong enough to transfer
himself from his bed to a wheelchair, Jones said.
“It
just felt like we were tossing our seniors and disabled adults,” Jones said of
the letters, which arrived in September 2018 and sparked a year-long dispute.
“‘Sorry, we’re going to save some money here.’ That’s exactly what it felt
like.”
The
California Department of Health Care Services, which administers Medi-Cal, the
state’s Medicaid program for low-income people, said the terminations by the
managed care plan, CenCal Health, were isolated, a perspective some long-term
care advocates share. CenCal said it was just following protocol, examining the
books to make sure members still met the qualifications for long-term care
under Medi-Cal.
But
California Healthline interviewed multiple long-term care advocates and legal
aid attorneys on the Central Coast and other parts of the state who said they
have witnessed an increase in coverage denials for nursing home residents
covered by Medi-Cal managed care plans. They worry such denials may soon become
more commonplace: Medi-Cal nursing home care in all 58 counties will be placed
under managed care beginning in January 2021, the state announced recently — up
from 29 counties currently.
Under managed care, the state
pays plans a monthly rate for each recipient to provide all of the medically
necessary services that person needs. By comparison, under traditional “fee-for-service”
Medi-Cal, the state compensates medical providers directly for each service
they render.
California
and other states increasingly are moving their Medicaid patients into managed
care, arguing that the model saves money and also improves members’ health by
coordinating care. More than 80% of the 12.8 million Californians
on Medi-Cal are covered by managed care.
Long-term
care advocates fear that the trend means more frail people will be forced out
of nursing homes as managed care plans look to their bottom lines.
“We’re
looking at multiplying this problem across the state,” said Leza Coleman, executive
director of the California Long-Term Care Ombudsman Association.
The
typical nursing home population in California is about two-thirds Medi-Cal, and
many have given up everything — their apartments or mobile homes, their
furniture, their burial insurance — to qualify, said Lonnie Golick, ombudsman
for Shasta, Trinity, Siskiyou, Modoc and Lassen Counties in Northern
California. Golick said she’s received a number of complaints against
Partnership HealthPlan of California about coverage terminations. “They gave up
their whole life,” she said. “And then they’re told, ‘It’s time to go.’”
Exacerbating
the problem, Coleman added, is a shortage of assisted living facilities willing
to serve Medi-Cal patients who no longer qualify for nursing home care.
To be
eligible for nursing home coverage under Medi-Cal, individuals must have
medical needs that require continual, around-the-clock care to prevent
significant illness or disability, or alleviate severe pain.
CenCal
sent the termination letters to the San Luis Obispo County nursing home
residents as part of the process of reviewing their eligibility, said Bob
Freeman, CenCal’s CEO. Normally that process is spread out over the year, he
said, but the plan got “backed up” on evaluations, which is why so many
patients were notified at once.
“We
don’t like to do this,” he said. “It’s destabilizing; we don’t want to disrupt
people’s lives. We do have state regulations that we have to follow.”
Last
month, the Department of Health Care Services sent Medi-Cal managed care plans
a notice clarifying that federal law allows residents to stay in nursing homes
to receive “intermediate care”; in essence, plans should pay for lower levels
of care rather than terminating coverage.
Freeman
said the plan is reconsidering some residents’ eligibility, given the
clarification. And Jones, the San Luis Obispo ombudsman, said CenCal recently
hired a new nurse who has begun restoring eligibility for some residents in
certain homes.
But
residents of other homes — and in other regions — are still facing denials.
David
Green, 60, a registered nurse in Santa Barbara County, said his 90-year-old
mother received a letter last year telling her CenCal would no longer pay for
her care at Marian Extended Care Center in Santa Maria.
She’d
landed in a nursing home in 2016 after a bout of sepsis, he said. At first, she
was so weak, she couldn’t walk. By the time she got the letter, her strength
had improved, but she still had diabetes, kidney disease, hypertension, atrial
fibrillation, breast cancer, memory loss and pain in her artificial knees,
Green said.
Green
sought out the Santa Barbara County ombudsman and, later, a lawyer. Eventually,
he prevailed — but he’s always on alert for another letter.
“It’s
very nerve-racking,” he said.
Tessa
Hammer, the attorney from Legal Services of Northern California who helped
Green, said she has worked on seven such cases out of Santa Barbara County, as
well as a handful in the state’s rural northern counties. She’s concerned about
residents who don’t have family advocating for them.
“I’m
not sure where those folks might end up,” she said.
Golick,
the ombudsman for several northern counties, said a man in his 80s in Trinity
County received a notice from Partnership HealthPlan earlier this year that he
was no longer covered for nursing care he’d depended on for a decade. Like many
elderly residents, she said, he felt he had no choice but to comply. He told
her he might sleep on someone’s couch, or in his brother’s car.
“Rural
areas are really scary,” she said. “Where the hell do you go?”
Dustin
Lyda, a spokesman for Partnership, said the plan doesn’t track data on these
kind of coverage denials, but anecdotally hasn’t noticed an upsurge. Lyda said
the plan works with facilities, doctors and family members to determine a
patient’s needs. If Partnership determines skilled nursing is no longer
medically necessary, it works for 60 days to find an alternative solution, he
said.
In the
meantime, nursing homes find themselves in a difficult situation. They cannot
legally discharge residents who
don’t have a safe place to go, but they are no longer paid to keep them. In
some cases, including in San Luis Obispo, nursing homes have kept residents
without pay.
“We’re
all watching this closely,” said Craig Cornett, CEO of the California
Association of Health Facilities.
This KHN story first published on California
Healthline, a service of the California Health Care Foundation.
No comments:
Post a Comment