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New OIG Report, But Same, Ole Results: Medicare and Medicaid Fraud Persistent in PCS

How many times have you heard, “Third time’s a charm?”If that is true, then what is the fifth time? The sixth time?

In an October 3, 2016, advisory report, the Office of Inspector General (OIG) recommends that the Center for Medicare and Medicaid Services (CMS) heighten its scrutiny on personal care services (PCS) in states across the country. The OIG claims “that home health has long been recognized as a program area vulnerable to fraud, waste, and abuse.” Past OIG reports have focused on Medicare. This new one focuses on Medicaid.

OIG is a division of the U.S. Department of Health and Human Services (HHS) and is charged with identifying and combating waste, fraud, and abuse in the HHS’s more than 300 programs. But, evidently, OIG is not happy, happy, happy, when HHS disregards its findings, which appears to be what has happened for a number of years.

PCS are nonmedical services for people who need assistance with activities of daily living (ADLs), such as bathing, eating, and toileting. Most of the time, PCS are allowing the person to remain in his or her home, instead of being institutionalized. However, according to OIG, PCS is fraught with fraud.

PCS is an optional service for Medicaid, i.e., states can choose to cover the cost of PCS with government funds. But, on the federal level, PCS is provided, if medically necessary, in all states.

The OIG report summarizes Medicaid fraud schemes from November 2012 through August 2016. OIG goes on to say that the fraud in this report is merely replicate of Medicare fraud found in a prior reports. In other words,OIG is basically saying that it has found Medicare fraud in home health in multiple, past reports and that CMS has not followed through appropriately. In fact, this report makes over five times, in recent years, that OIG has instructed CMS to increase its regulatory oversight of Medicare/caid personal care services. How many times does it take for your spouse to ask you to take out the trash until you take out the trash? Third time’s a charm??

Mark my words…in the near future, there will be heightened investigations and increased audits on home health.

Here are some scenarios that can trigger an audit of home health:

  1. High percentage of episodes for which the beneficiary had no recent visits with the supervising physician;
  2. High percentage of episodes that were not preceded by a hospital or nursing home stay;
  3. High percentage of episodes with a primary diagnosis of diabetes or hypertension;
  4. High percentage of beneficiaries with claims from multiple home health agencies; and
  5. High percentage of beneficiaries with multiple home health readmissions in a short period of time.

While the above-mentioned scenarios do not prove the existence of Medicare/caid fraud, they are red flags that will wave their presence before health care investigators’ faces.

Here are the states (and cities) which will be targets:

Notice that North Carolina is not highlighted. Notice that Florida is highlighted and contained numerous “hotspots.” Certainly that has nothing to do with the abnormal number of people on Medicare…

Regardless, North Carolina will get its share of Medicare PCS audits. Especially, considering that we have the 7th most number of Medicare beneficiaries in the country – that should have gotten us highlighted per se.

Since the OIG Portfolio report issued in 2012, OIG has opened more than 200 investigations involving fraud and patient harm and neglect in the PCS program across the country. “Given the significant vulnerabilities in the PCS program, including a lack of internal controls, and that PCS fraud continues to be a persistent problem, OIG anticipates that its enforcement efforts will continue to involve PCS cases.”Report.

Fifth time is a ______?? (Sure thing).

Compelling Personal Care Workers to Pay Union Dues Violates Our Freedom of Speech: But I Still Have to Pay My HOA Dues!

I live in a community that requires homeowner association monthly dues.  We have a homeowner association (HOA).  More than once I have complained at the high cost of these monthly dues and the absurd endeavors on which our HOA spends my money.  For example, we had a beautiful, clay tennis court.  If you have ever played tennis on a clay court, you know how wonderful it is to play on clay.  Clay tennis courts are also expensive to build.  A few years ago, my HOA decided to turn the clay tennis courts into a gardening center.  In place of the tennis nets, they built 10-12 raised beds to which the homeowners could purchase rights to use.  Somehow, my HOA determined the clay tennis court would be better used as a place to hold raised beds instead of playing tennis.

Despite my intense disapproval of this decision, I was forced to continue to pay my HOA dues, and a part of my HOA dues was spent on the conversion from tennis court to garden center.

Not completely dissimilar, in many states, public sector workers are required to contribute to union dues, even if they disagree with the union’s actions.  In-home care workers are considered public sector workers in Illinois because they care for the disabled and elderly and accept Medicaid money.  Including Illinois, 19 states allow bargaining agreements for home care workers.

Last week the Supreme Court sent shockwaves to the 19 states that allow bargaining agreements with home care workers.  The Supreme Court held that Illinois cannot compel personal care workers to pay union dues.

You may be asking yourself, why is Knicole blogging about an Illinois lawsuit and union dues.  How in the world does this affect North Carolina health care providers who accept Medicare and Medicaid?

The narrow answer would be that the case has no effect whatsoever on NC health care providers.  Unlike Illinois, North Carolina does not allow public sector bargaining.  In fact, in NC, union contracts, or bargaining contracts for public sector employees are considered “illegal, unlawful, void and of no effect.”  N.C. Gen. Stat. 95-98.

A broader view, on the other hand, is to understand that increases or decreases in personal care wages, better or worse benefits provided to personal care workers, and the overall profit or loss of personal care workers across the country, is relevant to NC personal care workers, and I prefer this broader view.

In the Supreme Court case, Harris, et al v. Quinn, Justice Alito wrote that compelling public sector workers to compensate a third party to “speak” for them, even if the worker disagrees with the third party’s speech violates the First Amendment.

In the Supreme Court opinion, Justice Alito writes:

“If we accepted Illinois’ argument, we would approve an unprecedented violation of the bedrock principle that, except perhaps in the rarest of circumstances, no person in this country may be compelled to subsidize speech by a third party that he or she does not wish to support.”

Individual states determine labor laws related to government employees.  As previously stated, NC bans bargaining agreements.  Virginia does as well.

In states that do allow bargaining agreements, if workers did not want to participate in the bargaining unit, the worker would opt out of full dues and pay only the cost of grievance administration and collective bargaining.  Supposedly, this prevents the nonmembers, who benefit from the reward of collectively-bargained higher wages or better benefits, from reaping the benefits without paying for them.  The whole “free-ride” idea…

In Illinois, Service Employees International Union (SEIU), a bargaining unit, argued that personal care workers should be compelled to contribute to it because personal care workers are public sector workers.

SEIU claims that it gets higher pay and better benefits for personal care workers.  Approximately 1 million of the 3 million personal care workers nationwide are members of SEIU or other similar organizations.

However, the Supreme Court disagrees.  According to the Harris decision, I shouldn’t have to pay for HOA dues if I disagree with the HOA’s actions (I’m kidding.  Sadly, I have no case to cease paying my HOA dues).

Proponents of unions are not happy with the results, but let’s play out a hypothetical…what if the Supreme Court held that public sector workers were required to pay union dues, even against their will….

Because, think about it…the government cannot prevent us from contributing to political candidates nor can the candidate force you to contribute to a political campaign.  Upholding the freedom of speech is not necessarily anti-union.  The Supreme Court did not rule “against” unions per se.  It ruled that a bargaining unit is “bargaining for” or “speaking for” its members.  And you cannot be forced to pay for speech with which you disagree.

Free speech allows all of us to individually decide which principles to support.  Allowing personal care workers to choose not to support certain ideologies is not an attack on collective bargaining.  Rather, it ensures that the free choices of personal care workers are represented by any union entity, rather than union leaders benefiting from coerced fees.

While the Harris decision does not apply to me and my HOA dues for many reasons, including the fact that I chose to live in the community knowing that the HOA existed, the Harris decision does have possible broad ramifications, especially as to in-home care workers and other public sector workers.  It may mean that the 1 million in-home care workers now compelled to contribute to unions may have standing to stop if they so choose.

Smoke and Mirrors: ECBH Increasing Medicaid Rates (But Decreasing the Amount of Services Authorized?)

I am always amazed at magicians.  David Copperfield, David Blaine…

I once saw David Copperfield live.  I was convinced prior to the show that I would be able to determine how he performed the illusions. I just KNEW that I would see the strings or the trapdoor. But I did not. I was thoroughly amazed. Despite the fact that I still know that magic is not real, I was still awe-struck and entertained.  Realistically, magic is just smoke and mirrors. But, dag  on, those smoke and mirrors do a fantastic job.  At times, while watching a magic show, I find myself actually believing in magic. That is the power of smoke and mirrors.

Smoke and mirrors do not only appear in magic.  Many politicians are expert wielders of smoke and mirrors.  So to are many salesmen. And, apparently, East Carolina Behavioral Health (ECBH).

An article was published on NC Health News’ website yesterday. “Medicaid LME Updates: Cumberland/Alliance to Merge, Good News from ECBH.” Article is good. Information is good. But the ECBH news, I find “smoky.”

Click here for the article by Taylor Sisk

According to the article, “ECBH will increase the rates for psychological testing by 10 percent, personal care services by 16 percent, peer support by 7 percent and facility-based crisis and detoxification services to cover the full cost of the service.”

On the surface, the increase in rates that ECBH is implementing sounds great, right? In my head, I thought, “Wow! ECBH is doing some great marketing. Providers will want to work with ECBH…”

The problem is that the “surface level” or rate increase “on its face” is never the whole story. (Which is why ECBH’s rate increase is such an amazing use of smoke and mirrors. Most people will never see past the smoke).

The MCOs are prepaid. If the MCOs’ do NOT contract with providers and NOT authorize services, profits rise. 

But would an MCO REALLY deny medically necessary services, theoretically, to INCREASE profit?? You can decide.

However, one of my clients hired me because ECBH denied 100% of continuing authorizations and new referrals for ACTT services in Pitt County.

ONE HUNDRED PERCENT!

What are ACTT services?

DMA Clinical Policy 8A defines ACTT services:

The Assertive Community Treatment Team [ACTT] is a service provided by an interdisciplinary team that ensures service availability 24 hours a day, 7 days per week and is prepared to carry out a full range of treatment functions wherever and whenever needed. A service beneficiary is referred to the Assertive Community Treatment Team service when it has been determined that his or her needs are so pervasive or unpredictable that they cannot be met effectively by any other combination of available community services. Typically this service should be targeted to the 10% of MHDDSA service beneficiaries who have serious and persistent mental illness or co-occurring disorders, dual and triply diagnosed and the most complex and expensive treatment needs.” 

ACTT services are reserved for the extremely mentally ill.  These are the people who need 24-hour services; recipients receiving ACTT services are people who must receive the ACTT services to function.  Yet, ECBH denied 100% of my client’s new referrals and continuing authorizations.  One such denial was a Medicaid recipient who had been arrested 6 times since April 2012.  After the ACTT denial, the Medicaid recipient was again incarcerated, which is where the recipient is now.  Another denial resulted in the Medicaid recipient being hospitalized for suicidal ideation.

For recipients already receiving ACTT services, ECBH has forced my client to “step-down” the recipients to outpatient behavioral therapy (“OBT”). Of the Medicaid recipients that ECBH has forced Petitioner to “step-down,” three recipients were immediately referred back to ACTT when the OBT providers stated that the recipients suffered too high acuity of mental health illness to manage in OBT setting.  Two recipients were incarnated after discharge; the jail employees are complaining of psychiatric problems that are difficult to manage. 

Back in May 2013, the local news channel in Greenville, North Carolina, aired “9 On Your Side Mental Health Town Hall exposes problems, brings you answers.”  The news channel coverage demonstrates the possibility of the widespread breath of ECBH denials, in general. Maybe ECBH’s denials of medically necessary services is not limited to my client’s personal situation.

Regardless of the breadth of ECBH’s denials of medically necessary services, back in May 2013, ECBH was getting some bad marketing from the local news. So what does ECBH do? Raise reimbursement rates.

If, in fact, ECBH is denying many medically necessary Medicaid services in order to raise profit, then isn’t ECBH’s rate increase just smoke and mirrors?

Adult Medicaid Group Homes: Forgotten Again?

In the wake of such tragedies such as the Colorado movie theatre last July, the Sikh temple in Wisconsin in August, Minneapolis in September, then the unthinkable massacre at the Connecticut elementary school in December, and, of course, the Boston bombing in April, you would think that mental health would be a top priority.

Instead, politicians across America are advocating gun laws.  Without commenting on gun control (as this is a Medicaid blog), mental health seems to be getting placed on the back-burner.

In the North Carolina budget passed by the Senate last week, mental health, in particular, group homes for adults with severe mental illnesses, again, was forgotten.  Whether on purpose or by accident, I have no idea.  But the fact remains a large part of metal health simply was not contemplated in the budget.

I am sure most of you remember the comedy of errors that occurred at the beginning of the year when the criteria for personal care services (PCS) was revised.  Basically in January 2013, the criteria to receive PCS became more stringent.

According to DMA, effective January 1, 2013, PCS “is available to individuals who has a medical condition, disability, or cognitive impairment and demonstrates unmet needs for, at a minimum three of the five qualifying activities of daily living (ADLs) with limited hands-on assistance; two ADLs, one of which requires extensive assistance; or two ADLs, one of which requires assistance at the full dependence level. The five qualifying ADLs are eating, dressing, bathing, toileting, and mobility.”

Prior to January 1, 2013, individuals who qualified for Medicaid special room and board assistance were automatically granted approval to receive PCS funding regardless of need. This applied for both in-home and facility-based services.

Due to the more stringent 2013 criteria, thousands of adults in group homes in NC who depended on Medicaid were no longer eligible.  Former Gov. Perdue was forced to shimmy around funds in order to keep these disabled adults from losing their homes.  The whole debacle created terror and stress for those disabled adults whose residences were threatened, for the families of the threatened disabled adults, for the group home executives who did not want to evict these disabled adults, and for any mental health advocate or person with empathy toward the mentally ill.

The trainwreck of the adult PCS group homes only occurred 4-ish months ago.

Yet, lawmakers, seemingly, failed to address the recurrent problem of funding for group homes for adults with severe mental illnesses, who are no longer eligible for PCS, in last week’s budget passed by Senate.

Wednesday afternoon (if you work downtown, then you know what I am talking about) a group of protesters rallied outside the General Assembly clad in blue shirts, holding signs saying, “Save Group Homes!” and “Disaster Relief! Save my Home!,” and some simply said, “Help!”

The Senate’s budget failed to provide funds for approximately 1,450 people living in 6-person group homes.  Each group home resident currently receives $16.14 a day, or about $6,000 a year, from the state program.  The fear is that group homes are so underfunded as it is that any amount, no matter how small, of decreased funds would drive the group homes out of business, forcing residents onto the street.

In general, group homes are not huge money-makers for the owners.  The workers at a group home make approximately $9-10/hour.  Group homes must be staffed 24/hours/day and 365/days/year.  The group homes must use the state-funded money to staff the home, keep up the maintenance of the home, feed all the residents and care for all the residents, plus all overhead (i.e., electricity, heat/air conditioning, any extras for the residents, such as TVs or cable, blankets, etc.).  Plus group homes must provide a small, monthly stipend for the residents in order for the residents purchase medicine (co-pays) and personal hygiene products.

Logically there must be SOME profit in group homes in order for anyone to want to run a group home.  But the profit is minimal.

Similar to the low Medicaid reimbursement rates to physicians, causing physicians to not accept Medicaid, any sort of cut to group home funding (including the residents not qualifying for PCS due to the new criteria and without special funding to cover the difference), group homes will inevitably close.  You simply cannot expect a person to keep a group home open when no profit is made.  Just as if you cannot expect a doctor to accept Medicaid patients if no profit is made.

So, is the State of North Carolina saving money by not providing additional funding to those PCS recipients who no longer qualify for PCS? Hey, the Medicaid budget goes down, right? But what happens to those adults with severe mental illnesses when, because of the lack of PCS funds, the group homes either close or turn out those residents who no longer qualify for PCS?

In a perfect world, I guess the families of the adult Medicaid recipients would take them in and all would be fine.  But I gather there is a reason that these recipients are in a group home and not with family.

No, since this is not a perfect world, most of these adults with severe mental illnesses, without a group home, would be homeless and, eventually, if not immediately, would be hospitalized at a much higher price that a group home.

So these adult Medicaid recipients are stable in a group home. Well-cared for. Most likely, have relationships with the staff and other residents.  But because of the new PCS criteria and the fact that the NC budget does not provide funding for Medicaid residents that no longer qualify for the PCS funding, we will uproot the adults with severe mental illness, send them into the world, expect them to be ok, and, then, later, pay much more money to the hospitals that are forced to take in these Medicaid recipients due to whatever issues caused the hospitalization.

Hmmmm….at least the Medicaid budget is lower.

CCME’s Erroneous Denials: DMA’s Attempt to Explain

For months health care providers in North Carolina that accept Medicaid and that are undergoing cumbersome audits by the state have been asking, “Why are these claims being denied?” and “Show me in the DMA Policy where my documets are noncompliant.”

Finally, in North Carolina Division of Medical Assistance’s (DMA) March 2013 Medicaid Bulletin, DMA (long overdue) attempts to analyze information from the Carolina Centers of Medical Excellence (CCME) and to provide health care providers with concrete examples of documentation errors that have caused CCME to deny claims.  Good job, DMA. Since CCME was awarded the contract to conduct the prepayment reviews back in 2009,  we are so excited to see concrete feedback now in 2013.

So a little late, but the information is there, right? WRONG.

From my experience as an attorney for health care providers undergoing these prepayment reviews, the documentation errors listed in the March 2013 Medicaid Bulletin are misleading, incorrect, only partially explanatory, and outright wrong.

To read the entire March 2013 Medicaid Bulletin click here.

According to the March 2013 Medicaid Bulletin: these are the trends of documentation errors identified: (For the sake of time (my time) I will only discuss PCS, but the problems in PCS are ever-prevalent in other services. The March 2013 Medicaid Bulletin lists “trends” for Durable Medical, CAP, and outpatient speech, as well. But I will need to devote future blogs to each topic.)

The March 2013 Bulletin reads, in part,:

To date, the following trends have been identified:

Personal Care Services/In-Home Care (PCS/IHC):

  • Providers and their staff were not qualified to supply the services billed;
  • Examples include inappropriate levels of certification, lack of policy-required background checks and failure to meeting staff training requirements, among other things;
  • Lack of service documentation, for example missing signatures;
  • Plan of care was not followed and any deviation from the Plan of Care was not documented;
  • Supervision was not conducted per clinical policy requirements.

(The Bulletin continues past this, but I will concentrate on PCS/IHC).

Let’s analyze each “trend:”

1.  Providers and their staff were not qualified to supply the services billed.  The below picture  depicts aan actuual ddenial from CCME.  Staff qualifications is reason Q11.

Image

In the picture above, read “reason for denial” Q11. That is the complete explanation provided by CCME for denying a claim because of “unqualified” staff.

CCME does not provide the provider with the name of the questionable staff member.  No information as to what exactly is missing. No explanation as to how the documentation does not support the staff is qualified. Nothing. The provider is left guessing and perplexed because, in actuality, CCME is in possession of the qualifications of all staff.

It is important to note that, at the outset, at the very beginning of the audit, the provider is required to supply CCME the qualifications for every single staff member employed by the provider who is serving the Medicaid recipients.  Therefore, CCME has in its possession all qualifications of all staff throughout the process.

In the above denial, the staff member who provided the services was completely qualified to provide the services.  The staff member met all criteria.  However, in this case, CCME was unable to decipher the staff member’s signature.  Instead of contacting the health care provider and asking which staff member’s signature was on the document, CCME merely denied the claim.  I mean, isn’t it easier to deny the claim than pick up the phone to determine if, in fact, the staff member was actually qualified?

Next example:

2.  Examples include inappropriate levels of certification, lack of policy-required background checks and failure to meeting staff training requirements, among other things;

This is actually not a different reason from #1.  This is DMA trying to give examples of #1, although, again, see above for the reality.

Next example:

3.  Lack of service documentation, for example missing signatures;

This may be my favorite example that DMA gives as a reason for denial. Because, of course, if a service note is not signed, the service note is invalid.  However, CCME does not give “lack of signature” as a reason for the denial. Instead, ithe denial looks like this:

image

See Q5: No valid treatment plan/PCP in place for the date of the service billed.  The denial for a service note is identical; there is no valid service note for the date of service billed.

There is zero explanation as to why the service note is invalid. Was there a service note at all? Was the service note misdated? Not signed? Not dated?  Zero explanation.

In the denial above, an authorization was actually in place for the date of service and the provider submitted a valid treatment plan. Yet CCME still denied the claim. Why? Well, I cannot pretend to understand the thoughts behind this denial, but I was told by a CCME representative that the authorization was not in place for the particular date of service at issue here, but, in this, case, no authorization was required as the service rendered on this date of service was within the client’s first 16 unmanaged visits for Outpatient Behavioral Therapy (OBT), as the client was a child.  Apparently CCME missed that portion in Clinical Policy 8C.

As for the treatment plan, in this case, CCME stated the treatment plan was invalid because the provider had not hand signed the treatment plan.  This provider, per DMA’s electronic signature policy, had complied wth all requirements in order to electronically sign all documents.  However, apparently CCCME failed to review the electronic signature policy.  Because, erroneously, this claim was denied.

Next example:

4.  Plan of care was not followed and any deviation from the Plan of Care was not documented.

image

Read reasons for denial Q8, Q10, and Q 12.  When I first read this explanation by DMA as to why CCME is denying claims, I said, “Huh?”  But then I thought back to the reconsideration reviews and hearing with CCME representatives that I have had.  In my experience, CCME reps have read service notes, the goals on service notes, and told me that the goals on the service notes did not reflect the goals in the PCP or treatment plan.  Whereas, when I read the PCPs or treatment plans, I subjectively read the goals on the service notes as absolutely encompassing the goals written on the PCPs or treatment plans.  Let me be clear: Whether a Plan of Care was or was not followed (per the service note) is a subjective decision. Where I may believe that the plan of care was absolutely followed, someone else may disagree.  (My opinion on CCME being allowed to make subjective opinions in this very important audit process will have to be the subject of another blog). Nonetheless, for DMA to state that there have been findings of plans of care not being followed when I have found that, in reality, the CCME denials are subjective, and, in many cases wrong, I find DMA’s examples of issues found misleading.

In the case in which the above denial was at issue, (for the sake of brevity, I will only review the denials at issue in this blog, but every one of these denials were erroneous)

  • Q8: Documentation does not reflect clients’ response to therapy: Here, the service note (which to preserve attorney/client privilege I will summarize with no names) stated, “Jimmy showed positive signals when we explained that his mother would be more involved.  He expressed concern, but we talked about the possible outcomes. He left saying that he would work hard on the homework he was given.”  If that service note does not reflect the client’s response to  therapy, then someone needs to explain to me what detail is needed for a service note to reflect a client’s response.  Perhaps, CCME expects War and Peace.  Perhaps CCME expects details such as, Jimmy pursed his brow and rubbed his head when we discussed his mother.  Jimmy said, “My response to this therapy is that I do not want to speak to my mother.” Perhaps, the service note should have had a section bolded: “Jimmy’s response to therapy.” Perhaps that would be easier.
  • Q10: Service note does not reflect the specific treatment goal in the treatment plan/PCP: In this case, the PCP enumerated 3 goals.  One was stated as (summarized to protect attorney/client privilege), “Jimmy will control his aggression with authority figures, particularly his mother.”  The service note’s goal stated that “Jimmy will become more involved with his mother and remember that his mother is in charge.”  In my opinion, the service note goal is directly in-line with the PCP goal.  But, again, this is a subjective determination that has been placed in the hands of CCME.
  • Q12: Interventions provided are not individualized in order to meet the recipient’s diagnosis, clinical, and intellectual needs: What? How are mental health services rendered for a particular client, not individualized? Jimmy has issues with authority.  Did the provider talk about financial issues? THAT would be not individualized.

Regardless, the reasons for denial that are  issued by CCME (the reasons in the pictures) are completely different from the reasons for denials stated by DMA in March 2013 Medicaid Bulletin.  It seems the Medicaid Bulletin’s reasons for denial are more concrete and understandable.  Then why can CCME not provide better, more concrete and understandable reasons?

Instead, CCME is denying claims because the CCME rep cannot read the staff signature, instead of asking for the identity of the staff member.

At my last hearing in which a CCME rep testified, the CCME rep testified that if there is ever a question, a grey area, CCME errs in the favor of the provider.  Call me cynical, I don’t believe it.

General Assembly Back: Medicaid PCS Issue is HOT

NC legislators are back at work as of noon today (January 30, 2013). The most pressing issue in Medicaid? Personal Care Services (PCS).

In 2012, when the Medicaid rules changed (The rules didn’t change in 2012. The rules were determined to change in 2013) as to who could receive PCS, thousands of adults receiving PCS in adult care homes, suddenly, did not meet the criteria for PCS. Thousands of Medicaid recipients would no longer receive PCS; therefore, many group homes would go bankrupt.

Just to show the great breadth of this problem: The Office of Administrative Hearings (OAH) received 15,000 appeals this month from Medicaid recipients no longer eligible to receive PCS.

Expect to see a bill with a fix to the group home issue in the House Appropriations Committee on Thursday.

NC Group Home Residents Lose Medicaid Funds: May Lose Homes

NC residents who live in Medicaid-funded group homes suffer mental illnesses or developmental disabilities.  Group homes allow the residents a home-like atmosphere and 24/7 health care and personal care services, such as help with toileting, bathing, and eating.

The federal government informed NC that the state was using the wrong eligibility criteria for Medicaid recipients receiving personal care. Personal care services (PCS) is a paraprofessional service that covers the services of an aide in the recipient’s private residence or group home to assist with the recipient’s personal care needs that are directly linked to a medical condition.

To fix the eligibility problem pointed out by the feds, the General Assembly set up a $39.7 million fund to pay for adult care homes, but group homes were unintentionally excluded. If the legislators did not use the word “only” in the legislation, most likely, group homes would have been covered. But in “only” covering adult care homes, group homes were excluded.

The result of the General Assembly’s oversight is that approximately 1400 people may be homeless starting January 1, 2013.

Despite an outcry from the General Assembly for Purdue to call a special session, Purdue refused. Instead, last week, Purdue announced that she was moving $1 million dollars within the Department of Health and Human Services to pay for group homes through January 2013. This allows the group home residents one extra month before Medicaid funding is gone.

The General Assembly organizes January 9th, but is not scheduled to conduct business until January 30, 2013….the day Medicaid funding will cease for the group homes.