“My Care Ohio” could cut off your Long Term Care Benefits

My Care Ohio is cutting off Medicaid payments for some seniors who need long term care.  Without payment, the providers can’t afford to provide long term care.

The insurance companies that “manage” care for Ohioans who are covered by both Medicare and Medicaid have started to identify people who, in the opinion of employees of the insurance company employees, are not eligible for Medicaid and then have cut off Medicaid payments for those people.  To be blunt, this seems very much like the “death panels” that Republicans claimed would result from the never-adopted Clinton health plan.

For those who have not followed the My Care Ohio discussion from its start earlier this year, My Care Ohio is a system of “managed care” for people on both Medicare and Medicaid (called “dual eligible” but more accurately described as “dual covered”) in the populous areas of Ohio.  It is an attempt to control the state’s costs for long term care paid from the state budget.

When the implementation of My Care Ohio started earlier this year, I  tried to provide an overview on how the My Care Ohio program will work  (Managed care for Ohio Medicare/Medicaid “Dual Eligibles”) on February 22, 2014.  On February 28, 2014, I explained how My Care Ohio is an attempt to cut costs through insurance company command and control methods rather than empowering people to choose lower cost care by making it easier to qualify for in-home care Medicaid through PASSPORT or for the Assisted Living Waiver instead of maintaining the current financial incentive to choose a nursing home, with its higher cost per person (My Care Ohio: A Triumph of the Stick over the Carrot.)  On March 7, 2014, I described the decisions that dual eligibles must make when My Care Ohio comes to their county:  (1) whether to accept managed care for Medicare for this first year; (2) which Managed Care Organization to join; and (3) whether to accept managed care for Medicare for years two and three.  (Your Options in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”)  On March 13, 2014, I outlined what to choices to make when enrolling in My Care Ohio.  (What to choose in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”.)

When all of 2014’s enrollees were placed into the My Care Ohio program, I described how enrollees could minimize the likelihood that needed care services would be cut by opting out of Medicare participation in My Care Ohio (Keep your doctor separate from your Managed Care Organization in the “My Care Ohio” program) in my July 4, 2014 post.  On November 13, 2014, I reiterated my suggestions about My Care Ohio enrollment with the opening of the renewal period for next year.  (“My Care Ohio” Enrollment for 2015)

As it happens, just as we muddle through the 2015 enrollment period, we also get feedback from long term care service providers about the treatment of their clients/patients at the hands of the My Care Ohio insurance companies.  That feedback is not good news for Ohio’s dual-covered seniors.  The insurers are looking for people whom they can cut off from coverage using the opinions of insurance company doctors to justify their decisions.

These people would not have been covered by Medicaid in the first place if their own doctor had not determined that long term care was necessary.  So, for these people under insurance company scrutiny, we have a repeated difference of opinions between doctors.  It seems, however, that only the opinion of the insurance company doctor matters.

My biggest fear for people in the My Care Ohio program is that their managed care organization (i.e., the insurance company to which they are assigned, whom we will call an “MCO”) will reduce services (in order to cut costs) that the managed care organization/insurance company deems unnecessary.  For example, if the person is in a nursing home and is doing well, the MCO might decide that the person can go home and receive home care (with a resulting big reduction in costs.)  Sadly, my biggest fear seems to have come to pass.

These MCOs are quick to tell the people whom they de-fund that the insurance company hasn’t cut off their long term care.  If the long term care stops, that’s the decision of the care provider (nursing home, assisted living facility, or home-care provider, etc.)  That, however, is a disingenuous story.  The real story should be that the insurer is cutting off payments to the provider and the provider is not in a position to provide long term care for free.

Now, this process is not the insurers’/MCOs’ fault (not all their fault anyway.)  This is a state of Ohio decision to cut costs by cutting off care.  An MCO’s job is to be the actual “hatchet man.”

So, if you or a loved one is dual covered (both Medicaid and Medicare) in Ohio, protect against service cuts.  The best protection against unwise cuts in services is keeping your personal doctor and keeping your doctor away from undue influence by the MCO.  To avoid MCO influence over the doctor, I urge all people in the My Care Ohio program to:

  • Opt out of the Medicare portion of My Care Ohio;
  • Find out which MCO works best with the care providers (other than the doctor) that you would like to use and enroll with that MCO; and
  • Choose a Medicare supplement (not an Advantage Plan) from an insurer that is not one of the MCOs in the My Care Ohio program.
  • If you can’t get a supplement, then get the best Advantage Plan you can find, just make sure it’s not from a My Care Ohio MCO.

For example, a person who can choose between United Health Care  and CareSource as their MCO (as in Summit County where I live) would look at these insurers’ provider lists for the care providers that they prefer.  Then, the person would tell Ohio Medicaid that they choose to OPT OUT of Medicare’s participation in My Care Ohio.   Then the person would sign up for a Medicare supplement with a company other than United or CareSource.  (Get the supplement enrollment done before December 7.)  After taking these steps, the person’s doctor is paid by someone other than the MCO and would be immune to perceived pressure from the MCO to acquiesce to questionable care decisions.

Remember, in this second year of My Care Ohio, the program assumes that Medicare will be opted into My Care Ohio.  You must take steps to notify the program that you choose to opt out for Medicare.

For more information, visit Jim’s website.

Jim Koewler’s mission is
“Protecting Seniors and People with Special Needs.”

For help with long term care or with planning for someone with special needs,
call Jim, or contact him through his website.

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