Here is what I have learned this week, and I want to share it with you so you can know it too and prepare yourselves.

You know that we provide the same kind of care for seniors that may also be provided for by a home care agency or by a nursing home. This post is about how to pay for the care once a senior’s resources have been exhausted.

I already knew that the Home and Community Based Waiver, which is the name of the Medicaid payment plan for Adult Day Centers such as Aging With Grace, cannot be used until a Prior Authorization has been issued by the State Dept. of Medicaid services. I knew that the Prior Authorization process can sometimes take a long time because an appointment to meet with a social worker at the Medicaid office  must be made (be prepared to wait on the phone by the hour to talk with someone to make the appointment) by the family who is asking the government to pay for their loved one’s care , and after that documents must be produced by the family who is asking for care (income and bank statements, proof of Social Security benefits, copies of life and health insurance and burial policies, a list of any assets and documentation, receipts showing medical and care expenses, etc.) and after that an assessment has to be done by a doctor and a case manager, and after that there are more Medicaid forms to fill out and a doctor’s statement submitted. Each of these steps take a long time to accomplish because life is what it is.

But what I did not know was that the Prior Authorization, once obtained, would not enable a viable entity to be reimbursed for the care they had given to a Medicaid eligible person. In other words, even though someone had been through the process described above, and was receiving care at one facility, paid for with Medicaid dollars, and then they transferred to another facility, they would have to pay for the care out of pocket until a Prior Authorization for that facility was obtained, or the facility would have to provide free care until the Prior Authorization was obtained. We cannot afford to provide free care. That means that a low income family would have to care for their loved one 24/7 (the person we have been caring for requires feeding, toileting, bathing, dressing, grooming, and monitoring so she doesn’t walk out of the house and wander away) until they get Prior Authorization. It took the family we have helped four months to get Prior Authorization. And of course they are expected to provide care for their loved one AND do all the work to get the documentation at the same time.

I also learned that home care agencies do not have to have Prior Authorization. Please read the email I received on Thursday below:

From: Leah Settles [mailto:Leah.Settles@lhcgroup.com]
Sent: Thursday, May 19, 2016 11:41 AM
To: maryc@BGADD.ORG
Cc: Cameron Mills
Subject: Urgent need/ Be the voice for our Senior’s home healthcare needs

​ Mary,

Can you please pass this along to your list serve and any other groups to help rally our senior citizen supporters to take action AGAINST CMS enacting prior authorization for home health. It takes 1 minute (or less) to contact your legislators to OPPOSE this if you go to the “click here” in the email below.

If there are any questions, please contact me at Leah.Settles@lhcgroup.com or 859.229.3969 (cell) or Cameron Mills at Cameron.Mills@lhcgroup.com.

Details of the proposed legislation: Prior authorization would require a government official to review and approve a patient’s need for Medicare home healthcare even though it has been prescribed by his or physician, potentially resulting in dangerous care delays.  We are extremely concerned as gaps in care will most likely come at a time when patients are most vulnerable – the transition from hospital to home, putting medically frail seniors at risk for adverse events or costly hospital readmissions.

The demonstration also stands to increase costs to the Medicare program and taxpayers and place burdensome requirements on providers, who as you know, are already required to provide extensive documentation on patient eligibility for home healthcare services.

We need your help to stop CMS from enacting prior authorization for home health!

Please contact your Representative in Congress and ask him or her to sign the Price/McGovern sign-on to letter to CMS to oppose prior authorization for the Medicare home health benefit.  We also encourage you to get the word out in your community and write your local newspaper. 

CLICK HERE and follow the simple instructions to do any or all of the following:

Ø  Send a letter to your Congressman urging him or her to add their signature to the McGovern/Price sign-on letter to CMS

Ø  Send a letter to the editor of your local newspaper expressing concern

Ø  Tweet your lawmaker urging support for stopping prior authorization and asking them to sign on to the McGovern/Price letter

Thank you in advance for your support.  Together, we can stop the implementation of a home health prior authorization demonstration and protect access to timely care for our patients.

Leah McCain Settles

LHC Group/ Senior Management Liaison
cell: 859.229.3969 (direct)
leah.settles@lhcgroup.com

AND OF COURSE WE ALL KNOW THAT NURSING HOMES DO NOT HAVE TO HAVE PRIOR AUTHORIZATION.

AND WE KNOW THAT NURSING HOMES GET MEDICARE AND MEDICAID DOLLARS TO PAY FOR CARE AND ADULT DAY CENTERS ONLY GET MEDICAID DOLLARS.

IS IT JUST ME, OR DOES ANYONE ELSE WONDER WHY THAT IS?