James HowellStaff Writerjhowell@civitasmedia.com
January 16, 2013
Changes in the qualifications for adults reimbursed by Medicaid’s personal care services have left several in Ashe County without Medicaid benefits.
“There are some residents that have been denied coverage,” said Bevin South, the executive director of Ashe Assisted Living.
The new policy, effective Jan. 1, mandates recipients who are reimbursed by personal care services require assistance with at least three of five ADL’s (activities of daily living). These ADL’s include dressing, eating, bathing, toileting and mobility.
Recipients can also qualify for personal care services if they need extensive assistance in two of these categories.
This policy could reduce the number of people who qualify for Medicaid reimbursement. Before this new policy, adult-care home residents qualified for Medicaid reimbursement if they needed assistance with one ADL.
Under the new policy, Medicaid recipients must be evaluated by a Carolina’s Center for Medical Excellence (CCME) registered nurse in order to maintain their coverage.
“Before the new policy change took effect Jan. 1, we were able to bill at a per diem rate for every Medicaid eligible resident regardless of the amount of assistance they need with personal care,” said South in a news letter.
“Under this new program, our Medicaid eligible residents were required to have an independent assessment conducted by a nurse contracted through CCME, who then determine how many hours we, the provider, are now able to bill for in accordance with how much assistance the resident needs.”
Ashe Assisted Living currently has 36 residence. Seven of those residents have been denied coverage for personal care services, roughly one fifth of the facility’s residents.
This number could increase in the future.
According to South, only 60 percent of Ashe Assisted Living’s residents who are Medicaid eligible have been assessed and 25 percent of those did not qualify under the new policy and were denied.
“There have been a few residencies down state that have released their residents who no longer qualify for reimbursement, but we haven’t done that and don’t want to,” said South.
According to South, the bigger problem is the change in Ashe Assisted Living’s Alzheimer’s Unit, which was receiving 161 hours of reimbursement and now receives only 80 hours of reimbursement.
South said this cut will cost Ashe Assisted Living approximately $800 per month.
Since the policy change on Jan. 1, Ashe Assisted Living’s faculty and residents’ families have appealed the decision.
South said the appeals, if sent by Jan. 10, could cause the rates for the Alzheimer’s Unit to return to their 2012 levels. In spite of sending appeals for all but one patient, South hasn’t received any confirmation that funding will return.