May 10, 2017

State blames five-month bungling of Medicaid case on ‘computer glitch’

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Senior citizens at a senior center. Flickr

Last month, 82-year-old Viola Weir received a letter from the state that rejected her request for Medicaid benefits to pay for nursing home care.

The letter from the New Mexico Human Services Department (HSD) said she had not provided the state agency with “the mandatory documents we need to decide if you can get benefits.” As a result, the department denied Viola Weir her Medicaid benefits.

The very same letter also said her income levels and assets met the qualifications to receive such care.

That’s according to documentation that Tom Kovach, Weir’s son-in-law, sent to NM Political Report from HSD, the state department which processes federal benefits.

To Kovach, the letter didn’t make sense.

“In the same letter it says she’s qualified but it didn’t get [her] documents,” he said. “It just completely contradicts itself.”

A spokesman with HSD did not return emails or phone calls from NM Political Report seeking comment on this story.

By documents, Kovach is referring to Viola Weir’s financial statements that he and his husband, Will Weir, sent to the HSD as part of her Medicaid application on Dec. 5. Both Kovach and Will Weir, the son of Viola, say the case should have been a no-brainer. Viola had previously been on Medicaid for years while she worked at a restaurant.

Then, last November, her medical conditions made living in a nursing home a necessity. Kovach and Will Weir helped her apply for Institutional Long Term Care Medicaid, a type of federal benefit that pays for the elderly poor to receive care in nursing homes.

Will Weir said that on Dec. 15, an HSD caseworker told him his mother’s previous history with Medicaid would make processing her application “the easiest case ever.” One week later, HSD sent a letter acknowledging receipt of Viola Weir’s financial documentation—the same documentation that four months later it said it didn’t have and rejected her case.

Months went by with no update from the state on the status of the Medicaid application. Meanwhile, Viola Weir’s unpaid bills at the Raton Nursing and Rehabilitation Center continued to pile up. The costs added to more than $20,000, according to the Kovach and Will Weir. The Raton nursing home did not comment on the matter for this story.

Federal laws prevent nursing homes from kicking out residents who are unable to pay for their care after they’re admitted. That means nursing homes can go unpaid for months at a time.

Finally, on April 5, HSD delivered the contradictory letter rejecting Viola Weir’s Medicaid benefits.

The four-month waiting period was much longer than the 45-day federal requirement for states to process Medicaid applications.

In the end, it turned out that HSD was in error in rejecting Viola Weir’s Medicaid application. They later attributed the mistake to a computer glitch, according to Kovach and Will Weir, and last week finally accepted Viola Weir’s Medicaid application.

“What should have been an easy case took five months,” Kovach said.

Not an isolated case

This isn’t the only time HSD has botched a patient’s Institutional Medicaid application, according to health care advocates and long-term care organization officials interviewed for this story.

“It seems to be a very pervasive problem,” said Collin Baillio, a spokesman for Health Action New Mexico, a nonprofit healthcare advocacy group. “In some of these cases these are the folks that need care the most, and it puts them in tough spots.”

Linda Sechovec, executive director of the New Mexico Health Care Association, which represents long-term care providers, said the long processing times “got a lot more difficult over the last year or so.”

“The big issue, of course, is any business would struggle with delivering services and then waiting for payments,” she said.

But Sechovec emphasized that both her organization and the state have been “working together to speed up hold times.”

She called cases that take four to five months to process—cases like Viola Weir’s—”extraordinary.” Sechovec said HSD has been willing to review such cases.

“For a family member this has to be exasperating, when they’re caught between eligibility and the facility not being paid,” she said.

Reasons for the long application processing times can differ. Sometimes the applicant is at fault. Or the complexity of the process for getting Institutional Medicaid can be daunting.

“Sometimes getting bank statements and information on assets takes longer than, for example, a young person bringing in their pay stubs or notices of when they lost their job,” Sechovec said. “If the family [applying] has everything, it moves a lot more quickly than if the family has to go on a treasure hunt.”

Overloaded HSD caseworkers and high turnover at the agency are problems, too, she said. As of early April, there were 431 vacancies at the agency, which fully staffed, should employ 2,084 people.

Senior Citizens Law Office Executive Director Ellen Leitzer said that clients applying for Institutional Medicaid often have to submit their financial documents to the state multiple times.

“That’s something we see, is documents being lost that we submitted, as in a lot of bureaucracies,” Leitzer said.

In Viola Weir’s case, Kovach and Will Weir made calls to HSD and the governor’s office before her situation was resolved. Eventually, Will Weir said, an Income Support Division staff manager explained the “computer glitch.”

“The way they explained it to me is if [the case] comes to five or six months, the computer automatically denies it,” he said.

If that’s true, both he and Kovach said the state’s wrongful rejections of people’s applications to Institutional Medicaid may be a frequent occurrence.

“From what they told us on the phone, there’s a lot of these cases and they have a committee reviewing them,” Kovach said. “For us, here’s a case that should have never been denied and yet was automatically denied.”

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