More People May Be Eligible for Adult Day Services

by David Gorn

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There was a glimmer of good news for the 35,000 adult day health care Medi-Cal patients in California. It looks like a much higher percentage of them than previously estimated will be eligible to receive the new benefit called Community Based Adult Services.

Department of Health Care Services Director Toby Douglas originally said he expected about 50% of current ADHC patients to qualify for the new program. ADHC will be eliminated as a Medi-Cal benefit on Mar. 31 and the CBAS program starts Apr. 1.

Now it looks like 70% to 80% of those receiving the ADHC benefit will qualify for CBAS, according to Catherine Blakemore, executive director of Disability Rights California, which is monitoring the state's assessment and placement of ADHC patients.

"Of the current people on ADHC, 70 to 80% will be eligible for CBAS services, and that means the assessments are working well," Blakemore said. "There may still be an issue with the presumptive eligibility criteria. There have been some difficulties with that."

The state delayed elimination of ADHC and startup of CBAS by a month. That exra time may help clear up disparities between the list of CBAS-eligible patients sent to providers and the notices sent to consumers, Blakemore said. Inconsistencies between the two lists has created some confusion about eligibility, she said.

That's pretty much where the good news ran out at yesterday's hearing where emotions occasionally ran high.

Most of the concerns raised were centered on three DHCS transition plans:

  • Conversion of seniors and persons with disabilities to managed care;
  • Transition of care for those who have been receiving ADHC services and now will get either the equivalent CBAS program or enhanced case management; and
  • The demonstration project to convert dual eligibles -- people who receive both Medicare and Medi-Cal benefits -- to managed care.

Policy changes of that magnitude affect a lot of people, and in these cases the health of several fragile populations, Katy Murphy of Neighborhood Legal Services of Los Angeles County said.

"We've been struggling very much with this transition. The last time we had one of these meetings, about three months ago, DHCS said they would learn from the lessons in this transition," Murphy said. "We are not seeing any evidence of that. None."

Often the same bureaucratic mistakes continue, she said, because DHCS hasn't had the time to incorporate any lessons into its current plans.

"We know you can make good policy," Murphy said, "but that takes time. You can't make policy when you move too quickly. It's important to learn lessons along the way. You have to understand, disruption [of services] can be more than disruptive to these people. It can lead to their death."

Brad Gilbert, CEO of the Inland Empire Health Plan, said that although there are always problems when you make transitions, these are doable.

"I come to this as a physician and a CEO," he said, "but as a doctor first."

He noted, "Integrating care and services is absolutely the right thing to do. Some of these transitions are difficult, but I think we can do this."

Patricia Samuelson, a Sacramento physician representing the California Medical Association, said there are daily trials and tribulations in the transition of coverage by the state. She had multiple anecdotes, including one patient who received regular doses of immunoglobulin, but was denied that drug by her managed care network. They wanted to see a recent test that proved her immunoglobulin was low.

"But she didn't have low immunoglobulin because she's been getting immunoglobulin," Samuelson said. "I was given a phone number to call, that number didn't work, I had a name and tried to reach that person in another way, that didn't work. It has been awful."

The worst part about it, Samuelson said, is that these are not rare horror stories. "These are the things that are not exceptional," she said. "This goes on all the time. This is my week."

Corinne Jan
I''m hoping that Catherine's estimate of 70-80% "will be qualified" is based on all the potential appeals pending. While our multidisciplinary team assessed that about 80% of our participants qualified, DHCS qualified only 40% of our 407 participants as eligible. We have filed 219 appeals.

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