Medicaid application delays are forcing Kansas nursing homes to turn people away

Dec. 15--Administrators at Villa St. Francis nursing home in Olathe have a checklist of questions before taking in a new resident with a pending Medicaid application.

How many Medicaid-pending residents are we already subsidizing? Is this person likely to survive the months it will probably take for the state of Kansas to approve their application? If not, is there a loved one who is willing to follow through on the application after this person dies?

Villa St. Francis CEO Rodney Whittington said they're questions he'd rather not have to ask. But after years of payments that didn't come for months, or sometimes didn't come at all, he and other nursing home administrators have to think hard about whether they can afford to take in another Medicaid-pending resident.

"We are one of the few, if not the only, facility in the KC area taking them still," Whittington said. "With the support of the church, it is our mission to meet those folks' need as best we can, but we've also got to have an involved family and someone who's going to answer questions and get us documents."

Kansas has had a backlog of Medicaid applications since late 2015. The agency that oversees the applications, the Kansas Department of Health and Environment, has whittled it down but never eliminated it. Last month the state reported about 2,000 applications pending past the 45-day federal limit, down from a high of almost 11,000.

Kansas Medicaid is called "KanCare," and is the main nursing home payment source for people who have exhausted their resources. Nursing homes have always had to wait for Medicaid approvals before they got paid, but before the backlog those waits were shorter and easier to absorb.

But for the last two years, homes have had to wait months or even longer and it's caused cash flow problems. Some have had to ask local governments for help to keep the doors open or ask utility companies for more time before they shut off the gas. Now fewer are willing to take in Medicaid-pending residents, especially if the patients are not likely to survive the application period.

Morgan Bell, a social worker at Stormont Vail Hospital in Topeka, told a KanCare legislative oversight committee last month that she was recently looking for a nursing home for a patient who had fallen into a coma.

"It came to my attention that even the couple of facilities that would make exceptions for KanCare-pending applicants are not able to take these patients if they have a limited life expectancy, solely because they will not receive payment if the patient dies before the application is approved," Bell said.

Karren Weichert, the CEO of a senior services organization called Midland Care, said it's not impossible to get a Medicaid application processed after the applicant dies, but it's very difficult. Applications for long-term care are the most complex in the Medicaid system, and require lots of financial documentation.

That can be difficult for family members to get after an account holder dies, especially if they don't have an attorney or an estate planner. Weichert said asking loved ones to try is the last thing providers want to do.

"At that point they're grieving," Weichert said. "They don't really want to work on paperwork to make sure somebody else gets paid for taking care of Mom."

Charles Watts of Leawood is trying to do the paperwork. Watts' stepfather, a World War II veteran, was admitted to Delmar Gardens in Overland Park in May and applied for Medicaid in July. He died Oct. 5, just after his 91st birthday.

Watts is still trying to get his Medicaid approved, and has hired Berger Estate & Elder Law in Leawood to help.

"While I could just step away having no obligation, especially now that Bill has died, if every single case ended up like that, there would no longer be skilled nursing facilities that will take people who are Medicaid-pending," Watts said. "With the escalating cost of health care and growing number of seniors in need, that's just something we can't ever let happen."

Molly Wood, an elder law attorney in Lawrence, said Susan Reynolds of Holton recently hired her to try and get Reynolds' mom into a nursing home. Wood said she had to assure the nursing home administrator that Reynolds' mom was eligible for Medicaid and Wood would stick with the application even if she died.

Then she had to convince the nursing home's parent company.

Reynolds, who had cared for her mother for the last three years, said she didn't know what she would have done without Wood.

"Being such an emotional time when you're trying to place your loved one, you're going through so much already with interviewing the staff at the facility and all the ins and outs of getting Mama in there that have nothing to do with the paperwork," Reynolds said. "I was already overwhelmed."

KanCare clearinghouse staffed by Maximus

In the past, people like Watts or Reynolds could walk into a local office of the Kansas Department for Children and Families and get help with the paperwork. Now they have to call a "KanCare Clearinghouse" in Topeka.

Gov. Sam Brownback created the clearinghouse through an executive reorganization in 2015 that funneled all Medicaid applications, including the ones for nursing homes, into the Kansas Department of Health and Environment. KDHE signed a contract with a private company, Maximus, to staff the clearinghouse.

About that same time the state went through a rocky roll-out of a new computer system for processing applications.

Then the Obamacare open enrollment period automatically referred thousands of people to Medicaid. A backlog of applications burgeoned to almost 11,000 and hit nursing homes particularly hard.

Whittington said that at one point last year, 44 of the 160 people at Villa St. Francis were Medicaid-pending, causing more than $1 million in uncompensated care.

He had to lean on the Archdiocese of Kansas City for financial support.

Other facilities also struggled. Salem Home in Hillsboro asked its city government to subsidize its rent for six months. Patricia Raasch, the CEO of Mission Village Living Center in Horton, said she had to beg utility companies and food vendors to delay bill collections. Officials at Sharon Lane Health Services in Shawnee, said last year that the backlog threatened to ruin them financially.

The federal Centers for Medicare and Medicaid Services, or CMS, got involved last year, ordering the state to submit a plan to resolve the backlog and report its progress twice a month.

The state and Maximus added more workers and gradually the number of applications pending more than 45 days went down. It dipped to 927 in May 2017.

CMS stopped requiring the twice-monthly status reports in July. But spokesman Johnathan Monroe said the federal agency is still monitoring the situation.

"We are committed to ensuring that the state comes into compliance with the required federal time frames for application processing," Monroe said via email. "CMS is working closely with Kansas officials to determine appropriate next steps."

Nursing facilities and elder law attorneys say the clearinghouse is still struggling.

They reported being on hold for 20 minutes or more when they call, before getting a random Maximus employee who has to find the case in the computer system, become familiar with it on the spot and then try to figure out the reason for the holdup. Several said they'd been asked to submit the same document multiple times, been sent documents through the mail with only 10 days to respond to them, and been given information they knew was wrong.

The state's 2015 contract with Maximus says "The contractor shall provide a high-functioning, efficient, eligibility processing center to provide eligibility determination services in an accurate, timely, effective and courteous manner."

Wood, the elder law attorney, laughed when that section was read to her.

"They're obviously in breach of contract," Wood said.

The Maximus contract is worth up to about $3.9 million from July 1, 2017 to Dec. 31, 2018. It expires at the end of 2018, but the state has the option to renew it for three more years.

Maximus spokeswoman Lisa Miles said via email that the clearinghouse has "made a number of improvements to support staff training to drive improved efficiency and accuracy."

"Ensuring timely application processing is a priority for Maximus and our staff because we understand how important KanCare is to the individuals and families we serve," Miles said. "We are working with the state on continuous improvements to reduce the time it takes to process applications."

The state said most of the applications that are now pending more than 45 days can't be completed because they require more documentation.

Another contract was supposed to help with that.

To fulfill a federal requirement, the state hired Accuity Asset Verification Services last year to provide a software program connected to banks to automatically verify financial information. The state pays Accuity $3.25 for each assets search.

The program went live earlier this year, but Angela de Rocha, a spokeswoman for the state, said it has a shortcoming: it can only provide a one-time snapshot of the applicants' bank balances, not the several months of past bank statements Medicaid applications require.

De Rocha said the state is using the system to process annual reviews for people who are already on Medicaid, but not new applications.

"It's disappointing it didn't turn out to be as useful as we hoped," de Rocha said.

A promising new program

A more promising solution appears to lie in a pilot program KDHE and Maximus began this year. The state assigned some nursing facilities to specific teams of workers, so those workers can get familiar with the facilities' pending cases and work with them to get them cleared.

Villa St. Francis is participating. Whittington said the more hands-on approach feels like how it used to be when applications were processed in DCF regional offices, and it's working. The facility got nine Medicaid approvals last month, bringing his number of Medicaid-pending residents down to 17.

In the meantime, Whittington and Weichert said they would like to see the state presume that people entering nursing homes are Medicaid-eligible and start the payments flowing until they determine otherwise.

Sen. Laura Kelly, a Democrat from Topeka, said she's open to the idea, especially for hospice patients.

The state already does that for pregnant women and Kelly said there should be similar urgency for hospice patients, who by definition are expected to live no more than six months.

"Do I believe there's fraud in Medicaid? Yes I do," Kelly said. "But do I think if we have presumptive eligibility for people moving from the hospital to hospice, they're going to jump at the possibility to get it even if they're definitely not eligible? I don't think so."

Andy Marso: 816-234-4055, @andymarso

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