New Adult Program Launches With a Few Issues Still To Be Resolved

by David Gorn

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It was January 2011 when the governor first red-lined the Adult Day Health Care program for elimination as a Medi-Cal benefit. Since then, it has been rescued, cut in half, eliminated altogether, reinstated and replaced.

Yesterday the replacement program, Community Based Adult Services, went into effect. For about 32,000 former beneficiaries of ADHC, the changeover will go relatively unnoticed. Most of the currently open centers are expected to remain open, and CBAS benefits are similar to those in the now extinct ADHC program.

"It's a culmination of months of hard work, developing a program that's appropriate and useful for former ADHC participants," Norman Williams of the Department of Health Care Services said. "We had a goal of a program that would allow people to remain independent and living in the community."

There are several unresolved issues with CBAS:

  • First and foremost, there is a contempt-of-court motion alleging the state has not followed terms of the settlement. Disability Rights California, which filed the contempt motion, and DHCS are trying to reach a settlement this week. If they can't come to an agreement, a hearing will be scheduled in U.S. District Court.
  • Many centers providing adult day services in California are for-profit businesses. The state has told centers that to be eligible for Medi-Cal funding through the new program, they must convert to not-for-profit status by July 1. That poses a significant hurdle for many centers. "The state might make exceptions in some cases," Williams said, particularly since the state needs to keep most of those centers open to provide services for the 32,000 people so far approved for the CBAS program.
  • The 7,800 former ADHC beneficiaries who were denied CBAS care may still appeal those decisions. There may be quite a few appeals; in some of those denials, the state had already given initial approval.

That is one of the central concerns in the contempt lawsuit. In some cases, nurses conducted face-to-face interviews, approved patient eligibility for CBAS but had their approvals reversed in subsequent reviews by nurse evaluators.

In the settlement agreement, the language spells out when reviews should be done: "Second-level reviews shall be conducted in all cases in which the outcome of a face-to-face assessment is that a Class Member is not eligible for CBAS."

It does not say, however, that reviews should be done of cases in which the patient is found to be eligible in a face-to-face assessment.

Williams said there's another way to look at it. A second-level review is different, he said, in that it only involves cases where a patient has been found ineligible. But every case with a face-to-face interview also included a review by another nurse, and that person does have the authority to change the first nurse's conclusion, Williams said.

"The face-to-face assessment includes the [quality assessment] component," Williams said. "When we developed the protocol collaboratively, when we trained the assessors and the centers, that included the review step for everyone."


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