Ongoing Medicaid case loses more in-home service hours

By Kate Hayden, editor@charlescitypress.com

After months waiting on an appeal to gain back service hours funded by Medicaid, Charles City resident Michelle Waidler says her savings were nearly tapped out when a state judge affirmed AmeriHealth Caritas’ decision to cut funding.

On a Wednesday morning in January, Waidler received a call that her in-home aide hours would be cut from six hours a day to 2½ hours, effective immediately.

Waidler was diagnosed with Parkinson’s disease in 2010, and is unable to walk, exercise, cook, do laundry, use the bathroom, grocery shop or attend appointments outside her senior apartment without assistance.

She will have to fit in as much of those things as she can in 2½ hours with an aide each day.

APPEAL DECIDED

In November 2016, the Iowa Department of Human Services approved Waidler for a Medicaid elderly waiver with 180 hours per month of in-home assistance at her senior apartment.

Waidler’s case started in July 2017, when AmeriHealth Caritas, her managed-care organization (MCO), decided to cut payments from 180 hours a month to 64 hours a month.

After her first appeal to AmeriHealth Caritas was denied, Waidler submitted an appeal for a hearing with DHS in September and participated in a two-hour hearing by phone with DHS and AmeriHealth Caritas representatives on Oct. 16.

It took almost two months to hear the final verdict from DHS — and in that time, AmeriHealth Caritas announced it would withdraw entirely from Iowa’s Medicaid management program on Nov. 30, transferring Waidler and thousands of other Iowans over to different MCOs.

AmeriHealth Caritas and the two other MCOs, UnitedHealthcare and Amerigroup, have publicly stated the businesses are losing money under the state’s new privately managed system. 

Matt Highland, interim public officer for DHS in November, told the Press at the time that Medicaid patients would be reassigned to one of the two remaining MCOs to prevent coverage gaps for patients. 

UnitedHealthcare accepted about 215,000 former AmeriHealth Caritas patients for coverage — including Waidler. 

The department is searching for a new company to join Iowa’s Medicaid program effective July 1, 2018, Highland added.

News of nearly 400 AmeriHealth Caritas employee layoffs came the same day Highland announced that the state will spend an additional $60 million this budget year for Amerigroup and UnitedHealthcare. The federal government will pay about $80 million more, totaling $140.4 million in additional spending for this budget year, The Associated Press reported.

On Dec. 4, DHS decided in favor of UnitedHealthcare, Waidler’s new MCO, which picked up her case and the ongoing appeal.

That month, her case manager had Waidler apply for an additional waiver program through DHS, which would have offered an additional 24 hours of in-home service each month. Waidler learned she was ineligible in January.

On Jan. 17, Waidler received a morning call from her home-aide agency, informing her she would no longer receive services twice a day.

“It comes down to money, or the lack thereof, because I cannot afford to pay $3,000-some per month. I’ve exhausted any savings that I had,” Waidler said. “I don’t see how they can do this on a few hours’ notice.”

UNDER NEW MANAGEMENT

In late November, UnitedHealthcare pressed Waidler to sign a new Consumer-Directed Attendant Care Agreement, consenting to 64 hours a month of in-home service hours.

“I felt it wasn’t justified,” Waidler said. “They said if they didn’t have something, that I would probably get lost in the system, and that would be worse.”

Eventually Waidler signed, and UnitedHealthcare marked the agreement as under appeal, as the decision by DHS was still pending. Following the decision, Waidler said she was told no changes could be made to her case hours for a year after the appeal decision.

“Since August, we’ve been fighting one appeal after another,” Waidler said. “I can’t emphasize enough that I had straight Medicaid through the elderly waiver years ago. There has never been a problem like this. Never have I had to worry about things being covered.”

“As my needs changed, Medicaid kept up with the changes by increasing my hours.”

Since October, Waidler has missed two appointments with a neurologist, an orthopedic doctor, and additional vision and three dental appointments.

“I was told no transportation was allotted to me unless I private pay,” Waidler said. “The system isn’t helping people stay healthy.”

STATE PROPOSES OVERSIGHT REDUCTION

Amidst statewide scrutiny, DHS is proposing the Legislature roll back requirements of the state to oversee Iowa’s $4 billion privatized Medicaid program.

DHS officials requested a bill be filed last week in the Legislature that would reduce how often it must report performance data on the health care program for the poor and disabled.

The legislation would also remove some consumer protection metrics and eliminate a requirement that the agency report its expected savings under the privatized system.

The department insisted the bill will not worsen transparency and is aimed at increasing flexibility in presenting data to the public.

The wide-ranging proposal surprised lawmakers, both Republican and Democrat, who worked to enact oversight provisions in 2016 when the state program was turned over to the MCOs.

“We had all these different things that we wanted the department to report on,” said Rep. Dave Heaton, a Mount Pleasant Republican who worked on the requirements and reviewed the new legislation in a House subcommittee meeting last week. “Here comes this department bill … that wants to take away a lot of those sources or points of information.”

Highland, now the department spokesman, said the proposed changes are needed to give state officials more flexibility in structuring data to make it helpful to stakeholders. He pointed out some data points in existing reports are not mandated by law.

He also said the department plans to still include data about savings, but would instead describe it as “cost avoidance.” Removing the codified language helps allow that.

Iowa privatized its roughly $4 billion Medicaid program, which serves about 600,000 residents, in 2016. At the time, former Gov. Terry Branstad argued the new setup would be more efficient and save the state money.

Since then, health care providers and Medicaid recipients have filed complaints about reduced services and delayed reimbursements. Data on costs also shows the state hasn’t reached its intended goal on savings.

Gov. Kim Reynolds, a Republican who is seeking her first four-year term as governor, has acknowledged there have been mistakes in the program’s transition.

The department has vowed to make improvements, though the agency has released few specifics on its plans. Some legislators have taken action themselves, introducing several bills aimed at fixing different aspects of the Medicaid system.

Jane Hudson, executive director of Disability Rights Iowa, said in an email the Department of Human Services needs to provide more oversight, not less. She’s particularly concerned about language in the bill that would eliminate a requirement for the agency to make sure the MCOs continue benefits during an appeal process.

Disability Rights Iowa helped file a lawsuit against the state that claimed the privatized system has cut services for disabled patients, but the suit was dismissed.

“This bill looks like DHS is washing its hands of the state’s Medicaid responsibilities and is turning the keys to our health system over to private for-profit companies,” she said.

— The Associated Press contributed to this report.