California Medicaid regulations, however, have not reflected this change, continuing to refer to “skilled” and “intermediate” care. Federal Medicaid law at one time distinguished between “skilled” and “intermediate” nursing facilities, but those categories were combined into the “nursing facility” category in 1990, when the federal Nursing Home Reform Law was implemented. In this particular case, however, the complicating factor was a lingering glitch in California’s Medicaid regulations. If a person meets Medicaid financial eligibility standards, and demonstrates the need for a covered service, Medicaid must pay for that service. Your reaction may be the same as the residents’ - What? How can a Medicaid program, as the payor of last resort, simultaneously assert that a beneficiary needs nursing facility care but that the beneficiary’s care needs are insufficient for Medicaid coverage? The short answer: It cannot. Yes, the residents required nursing facility care, but because they allegedly did not require “skilled” nursing facility services, their nursing facility services were “intermediate care services” and not Medicaid reimbursable. When residents appealed, the facility explained its reasoning in more detail. The termination notices alleged that the residents no longer needed “skilled nursing facility services.” According to an article in the Sacramento Bee, the managed care plan CenCal Health on one day issued notices to end Medicaid nursing facility coverage for three dozen residents, including a 68-year-old amputee receiving kidney dialysis, and an 82-year-old man with congestive heart failure and diabetes who did not have the strength to transfer himself from bed to wheelchair. Last fall, news articles on Medicaid nursing facility evictions in California caught the attention of aging network professionals nationwide. But the shift to managed care leaves many Medicaid recipients susceptible to harmful coverage denials. 41, Issue 4.)Ī majority of states provide Medicaid long-term services and supports through managed care, and the number grows each year. The pdf for the issue in which this article appears is available for download: Bifocal, Vol.
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