Care home owner fights red tape for 'thriving' resident

2013-04-26T00:15:00Z 2014-08-25T07:41:28Z Care home owner fights red tape for 'thriving' residentBy ED KEMMICK ekemmick@billingsgazette.com The Billings Gazette

Cyndi Johnson has trouble believing that bureaucratic rules may force a Billings woman out of an assisted-living home and into a nursing home — at double the cost to taxpayers.

Johnson is the owner of Primrose Personal Care Home at 1228 Maurine St. in the Heights. The woman in question is Beth Riojas, 74, who has been unable to receive an emergency Medicaid waiver from the state of Montana, which would allow her to stay at Primrose.

If Riojas were allowed to stay at Primrose, the state Medicaid program could pay up to $70 a day for her care. If she is forced into a nursing home, Medicaid would probably pay about double that, Johnson said.

Jon Ebelt, a spokesman for the state Department of Health and Human Services, said the maximum rate that Medicaid will reimburse an assisted living facility is $70.65 a day. And because nursing-home residents must contribute to the cost of the care if they are able to, Medicaid pays about $131.80 a day for nursing home care on average statewide.

Johnson has been begging Richard Opper, director of the DPHHS, to grant Riojas an emergency waiver, but he says he can't, that his hands are tied by regulations and a spending freeze.

Johnson said she's not buying any of his explanations. If the department is running out of money, she said, it doesn't make any sense to force Riojas into a more expensive level of care.

"He's frittering away taxpayer money and forcing a lady out of her home," she said.

In the 17 years she has owned Primrose, Johnson said, she has never seen anything like this.

"What's happening here has never happened before," she said. "They have never put a complete and total freeze on emergency waivers."

Opper said the situation is not so simple. He said more than 300 people are on the waiver waiting list across the state, and several of them are in "exactly the same" circumstances as Riojas.

He also said that money couldn't be taken from the nursing-home budget and redirected to provide more "waiver slots." At any rate, he said, the freeze is in effect only until June 30, the end of the fiscal year.

Johnson said Riojas' case is particularly upsetting because Riojas had already been on the waiting list once, was granted a Medicaid waiver and then lost it as a result of bad decisions by her case manager.

In-home care and assisted-living care are not considered a Medicaid entitlement, Johnson said, but people are regularly granted waivers so they are not forced into more expensive nursing home care.

Riojas had been granted a waiver and until last May had in-home care paid for by Medicaid. Her troubles began when she received an $8,000 insurance settlement from an earlier car accident.

Because of that windfall, she was no longer eligible for Medicaid. But Johnson says such situations happen often, and case managers routinely help their clients "spend down" their resources to keep them eligible for Medicaid.

There is nothing untoward about that, she said. In Riojas' case, Johnson said, she needed dentures and a burial plan, which are legitimate expenses that could easily have used up her insurance settlement.

But no such options were offered to Riojas' daughter, who was managing her mother's affairs, and instead Riojas was dropped from Medicaid. Johnson said her health deteriorated so quickly when she lost her in-home care that she first went to a hospital emergency room and then to a nursing home — all paid for by Medicaid.

Opper, in an email response to Gazette questions, which he said were answered by members of his staff, said the department, after reviewing Riojas' case, did not agree that the case manager "had a responsibility for this individual once she lost her Medicaid eligibility."

But Johnson said that wasn't the point. The case manager should have helped her spend down her resources so that she didn't lose her eligibility in the first place, she said.

Denise Armstrong, director of Big Sky Senior Services, agreed with Johnson that it isn't unusual for people working with clients to come up with spending plans that will maintain their Medicaid eligibility.

"We do that for our clients," she said.

After Riojas went into a nursing home, she stayed there until February, when Riojas' daughter brought her to Primrose, saying she had enough private money to pay for her care there. She paid for the month of February, Johnson said, but then disappeared.

Johnson said she doesn't believe the daughter was acting maliciously, but apparently she was overwhelmed by the difficulties of caring for her mother. Riojas has been staying at Primrose, paying only a small amount of money from her Social Security benefits, and Johnson has been trying to get her an emergency waiver.

Riojas lost 80 pounds in the hospital and nursing home, Johnson said, but she is doing well at Primrose, and Johnson doesn't want to turn her out. That works for now because no one else has applied for a spot in the home.

If a paying customer does apply, Johnson said, she would have to think of the viability of the Primrose home and give Riojas' slot to the paying customer.

Johnson has also appealed to Gov. Steve Bullock, but he deferred to Opper.

Johnson said Bullock's predecessor, Gov. Brian Schweitzer, on two occasions specifically directed the health department to grant emergency waivers so residents of Primrose would not be forced into a nursing home.

Riojas herself had little to say, beyond expressing an opinion about the nursing home.

"I hated it," she said. "I like it here a lot better than the nursing home."

And that should be the main consideration, Johnson said.

"My incentive in keeping her here is that she wants to stay," she said. "She is finally thriving."

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