Medicaid Denials May Boot Some Seniors From Assisted Living

First, picture a nursing home. Main Street Assisted Living in Homer is the polar opposite of that. It’s a house. In the center is a living room and directly behind it a full kitchen. Hallways to the left and right lead to bedrooms and a downstairs office. Seventy-five-year-old Lily Mann says she came to the center seven or eight years ago.

Listen now:

“I was rescued by Adult Protective Services at the request of my doctor who said I was no longer safe to live at home. Now they want to throw me out. The state rescued me and now they want to get rid of me. It’s mind-boggling,” says Mann.

Mann says before, she was “falling and breaking things.” She still has balance issues. She recently fell and hurt her foot. She also needs help with basic hygiene. These are things so personal she’s embarrassed to discuss some of them.

“I get help with bathing. I get help with treating my recurrent yeast infections which I’m physically incapable of reaching. I get help with cleaning my sleep [apnea] machine. They do the usual stuff. They carry away all the wet diapers,” says Mann.

Now she might lose it all.

“I was just told I was denied,” Mann says.

When Mann says denied, she’s talking about her Medicaid waiver. Presently the state uses four types of waivers. The one we’re interested in is titled 1915-C or just the “C option.” Seniors who use the C option choose to live in their own home with a personal nurse, or in an assisted living home. But they must be eligible for institutional level of care. Simply put, they have to be able to gain admittance into a nursing home even though they are choosing not to live in one. Brian Richardson is CEO of Immediate Care. It’s a company that provides assisted living services to clients across the state:

“In 2013 there was a change in the Alaska State Regulations. The industry believes the interpretation of a certain two sentences in those regulations has led to people being declared ineligible for nursing home supports and therefore ineligible for these kinds of Home and Community Based Services,” says Richardson.

Senior Disabilities Services, or SDS, Director Duane Mayes disputes Richardson’s claims. He says the Department is controlling the Medicaid waiver programs just as it was always meant to; but one key development gives the impression that more denials are being mailed than should be.

“There were lawsuits from a long time ago specific to our Personal Care Attendant program and our Medicaid Waiver program,” says Mayes.

According to Mayes those lawsuits challenged SDS’ methods for assessing individuals’ eligibility for these programs. The appeal process the department provided people who didn’t agree with their assessment was also under scrutiny.

“And so we resolved those lawsuits. So literally for a period of seven to eight years we were unable to remove anybody that no longer met level of care from our waiver system,” explains Mayes.

Mayes says it was about three years ago that those lawsuits were settled. That’s around the same time Richardson says there was a jump in the number of people found ineligible.

“I think that’s probably the impact people are feeling is now when we do our job and we determine if a person continues to meet eligibility for the waiver program. If there’s a senior who can change for the better, and they no longer meet eligibility, then we need to address other types of services for those individuals,” Mayes explains.

Waiver recipients go through an initial assessment when they first apply and they are reassessed annually. Caregivers and residents at Main Street Assisted Living think the assessments don’t go far enough. They say they only focus on physical abilities like; can a resident feed themselves, can they turn over in bed, or go to the bathroom alone. Mayes defends the assessment. He says it’s the same process the department has always used. And the department’s findings are reviewed by a third party contractor.

There’s one more check on the process. People deemed ineligible are guaranteed an appeal. Right now Lily Mann is in the middle of appealing her denial. She’s gotten help from an attorney with the Office of Public Advocacy. The owner of Main Street Assisted Living says 9 out her 15 residents are at risk of losing their waiver.

“They’re going to be dumping a lot of people out. I can’t go back to where I was living. I guess I’d just be competing with everybody else for a senior apartment or something like that,” says Mann.

Even if Mann finds a place it’s unclear how she’ll pay for it let alone get the care she needs.

This is the first report in a three-part series. Next we’ll explore the state’s assessment process and options available to seniors in danger of losing their waiver.