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Some of California’s most susceptible nursing residence residents, a lot of whom have nowhere else to go, are receiving letters from their well being care plans saying they’re not eligible for long-term care.
In one notable instance, three dozen nursing residence residents in San Luis Obispo County had been knowledgeable on the identical day that their Medi-Cal managed care plan was slicing off fee for nursing residence care, mentioned Karen Jones, the county’s long-term care ombudsman.
The residents included a 68-year-old amputee with diabetes, reminiscence loss and kidney illness who required dialysis thrice per week, and an 82-year-old man with congestive coronary heart failure and diabetes who wasn’t sturdy sufficient to switch himself from his mattress to a wheelchair, Jones mentioned.
“It just felt like we were tossing our seniors and disabled adults,” Jones mentioned 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.”
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The California Department of Health Care Services, which administers Medi-Cal, the state’s Medicaid program for low-income folks, mentioned the terminations by the managed care plan, CenCal Health, had been remoted, a perspective some long-term care advocates share. CenCal mentioned it was simply following protocol, analyzing the books to verify members nonetheless met the qualifications for long-term care underneath Medi-Cal.
But California Healthline interviewed a number of long-term care advocates and authorized help attorneys on the Central Coast and different elements of the state who mentioned they’ve witnessed a rise in protection denials for nursing residence residents lined by Medi-Cal managed care plans. They fear such denials could quickly change into extra commonplace: Medi-Cal nursing residence care in all 58 counties will probably be positioned underneath managed care starting in January 2021, the state introduced not too long ago — up from 29 counties presently.
Under managed care, the state pays plans a month-to-month charge for every recipient to supply the entire medically needed providers that individual wants. By comparability, underneath conventional “fee-for-service” Medi-Cal, the state compensates medical suppliers straight for every service they render.
California and different states more and more are transferring their Medicaid sufferers into managed care, arguing that the mannequin saves cash and likewise improves members’ well being by coordinating care. More than 80% of the 12.8 million Californians on Medi-Cal are lined by managed care.
Long-term care advocates concern that the pattern means extra frail folks will probably be compelled out of nursing houses as managed care plans look to their backside strains.
“We’re looking at multiplying this problem across the state,” mentioned Leza Coleman, govt director of the California Long-Term Care Ombudsman Association.
The typical nursing residence inhabitants in California is about two-thirds Medi-Cal, and plenty of have given up every little thing — their flats or cell houses, their furnishings, their burial insurance coverage — to qualify, mentioned Lonnie Golick, ombudsman for Shasta, Trinity, Siskiyou, Modoc and Lassen Counties in Northern California. Golick mentioned she’s acquired various complaints in opposition to Partnership HealthPlan of California about protection terminations. “They gave up their whole life,” she mentioned. “And then they’re told, ‘It’s time to go.’”
Exacerbating the issue, Coleman added, is a scarcity of assisted residing amenities keen to serve Medi-Cal sufferers who not qualify for nursing residence care.
To be eligible for nursing residence protection underneath Medi-Cal, people will need to have medical wants that require continuous, around-the-clock care to stop important sickness or incapacity, or alleviate extreme ache.
CenCal despatched the termination letters to the San Luis Obispo County nursing residence residents as a part of the method of reviewing their eligibility, mentioned Bob Freeman, CenCal’s CEO. Normally that course of is unfold out over the 12 months, he mentioned, however the plan received “backed up” on evaluations, which is why so many sufferers had been notified directly.
“We don’t like to do this,” he mentioned. “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 despatched Medi-Cal managed care plans a discover clarifying that federal regulation permits residents to remain in nursing houses to obtain “intermediate care”; in essence, plans ought to pay for decrease ranges of care slightly than terminating protection.
Freeman mentioned the plan is reconsidering some residents’ eligibility, given the clarification. And Jones, the San Luis Obispo ombudsman, mentioned CenCal not too long ago employed a brand new nurse who has begun restoring eligibility for some residents in sure houses.
But residents of different houses — and in different areas — are nonetheless going through denials.
David Green, 60, a registered nurse in Santa Barbara County, mentioned his 90-year-old mom acquired a letter final 12 months telling her CenCal would not pay for her care at Marian Extended Care Center in Santa Maria.
She’d landed in a nursing residence in 2016 after a bout of sepsis, he mentioned. At first, she was so weak, she couldn’t stroll. By the time she received the letter, her energy had improved, however she nonetheless had diabetes, kidney illness, hypertension, atrial fibrillation, breast most cancers, reminiscence loss and ache in her synthetic knees, Green mentioned.
Green sought out the Santa Barbara County ombudsman and, later, a lawyer. Eventually, he prevailed — however he’s at all times on alert for one more letter.
“It’s very nerve-racking,” he mentioned.
Tessa Hammer, the legal professional from Legal Services of Northern California who helped Green, mentioned she has labored on seven such circumstances out of Santa Barbara County, in addition to a handful within the state’s rural northern counties. She’s involved about residents who don’t have household advocating for them.
“I’m not sure where those folks might end up,” she mentioned.
Golick, the ombudsman for a number of northern counties, mentioned a person in his 80s in Trinity County acquired a discover from Partnership HealthPlan earlier this 12 months that he was not lined for nursing care he’d relied on for a decade. Like many aged residents, she mentioned, he felt he had no selection however to conform. He instructed her he would possibly sleep on somebody’s sofa, or in his brother’s automotive.
“Rural areas are really scary,” she mentioned. “Where the hell do you go?”
Dustin Lyda, a spokesman for Partnership, mentioned the plan doesn’t observe information on these type of protection denials, however anecdotally hasn’t observed an upsurge. Lyda mentioned the plan works with amenities, medical doctors and relations to find out a affected person’s wants. If Partnership determines expert nursing is not medically needed, it really works for 60 days to seek out another resolution, he mentioned.
In the meantime, nursing houses discover themselves in a tough scenario. They can’t legally discharge residents who don’t have a protected place to go, however they’re not paid to maintain them. In some circumstances, together with in San Luis Obispo, nursing houses have stored residents with out pay.
“We’re all watching this closely,” mentioned Craig Cornett, CEO of the California Association of Health Facilities.
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Jocelyn Wiener: @jocelynwiener