A member of the Assembly Committee for Aging and Long-Term Care asked that the state Legislative Counsel look into variation in eligibility approvals for the state's new adult day care program.
That was one of many concerns raised during an Assembly oversight hearing yesterday examining the state's pending Oct. 1 implementation of much of its Community Based Adult Services program.
Toby Douglas, director of the Department of Health Care Services, which is overseeing implementation of the CBAS program, answered a number of questions from legislators about the state's new program designed as part of a settlement of a lawsuit challenging the state's plans following elimination of the Adult Day Health Care program.
"Our office has been recipient of concerns and complaints about the transition of ADHC to the CBAS program," said committee chair Mariko Yamada (D-Davis).
"We keep hearing so many concerns and complaints about the [unrealistic] workload, as well as the delays in appeals and the capacity of our network to get these services delivered," Yamada said.
"We are ensuring that our most vulnerable beneficiaries remain independent in the community," Douglas said. "We are centered on rebalancing care to ensure people can remain independent in the community."
Douglas acknowledged that implementing the CBAS program has been difficult, but said that after many months of preparation the program now is ready for full roll-out.
"Since the settlement began, there has been considerable progress," Douglas said. "By no means has it been smooth. It's a big transition, in a short period of time. But we're doing it in a way to ensure they keep receiving the vital services they need."
Douglas said about 80% of former ADHC beneficiaries have qualified for the new CBAS program -- a much higher number than the 50% he originally expected to qualify. Douglas said the 20% who were found ineligible for CBAS services have all been offered enhanced case management services.
Douglas added that 2,431 people found ineligible are appealing those decisions.
DHCS officially launched the CBAS program on July 1, with about 10% of recipients making the transition to Medi-Cal managed care to receive services. Douglas said there have been lessons learned from that transition, and the department has stepped up its communication and outreach effort.
"We've had nine different webinars, about 40 different instructional letters to providers, as well as notices sent to beneficiaries," he said. "So there is a lot of communication going on."
All contracts with health plans will be in place by Sept. 28, Douglas said. He said 95% of treatment authorization requests have been approved within 30 days.
"We are providing the right process so everyone has ability to have an assessment and a fair hearing," Douglas said.
The topic that struck the most sparks was ignited when Douglas said 80% of all new applications for CBAS eligibility have been accepted statewide.
That irked Assembly member Nancy Skinner (D-Berkeley).
"If that's true," Skinner said, "why is it that all of the providers I have checked with have said the rejection rate is 80%. This befuddles me."
"How is there an 80% acceptance statewide, but it's so low in my two counties?" Skinner asked.
Douglas said there are variations of eligibility depending on the centers. "Provider by provider there is a wide variation," he said.
"Just from a data point of view, that cannot be the answer," Skinner said. "The gap is huge, and across a number of providers. Are you saying all of our centers in our counties are somehow getting things wrong?"
"The process includes a fair hearing," Douglas said.
Skinner insisted she wanted to get a breakdown of eligibility statistics by county, but Douglas said that couldn't be done because of confidentiality issues and federal HIPAA regulations.
"I don't want to appear overly arch here," Skinner said to Douglas. "But put yourself in my shoes. With the answer you've given to me, would you be satisfied with it?"
Skinner formally requested a review of the issue by the Legislative Counsel. "I need to be satisfied," she said. "What is the breakdown that could be given that would give us some assurance that there's not an arbitrary ineligibility?"
Douglas also said he would discuss the issue with the state's privacy officer, and that the numbers are generally skewed to Los Angeles County, since that county has the bulk of CBAS applicants and beneficiaries.
Many of those declared ineligible have waited well beyond the 90-day deadline for a hearing. Douglas said his department, in concert with the Department of Social Services, hopes to clear up the huge backlog of hearings relatively quickly.
"We are under a tight timeline to make sure we don't hit that 90-day clock, so we plan to see about 200 cases per week," Douglas said. "We hope to clear the backlog by the middle of November."
That floored Yamada.
"How you are going to process 200 appeals a week?" she asked. "That would be a magnificent feat, in my opinion. I'm really amazed."
Yamada said she's all in favor of a timely appeals process, but doesn't want it to become a "factory appeals process," and she questioned whether enough administrative law judges could be found to carry out all of those appeals so quickly.
"I would definitely like follow-up information on that," Yamada said. "I'm sure Ms. Skinner will have quite a lot of them. … So let's have a follow-up on that one."