Lia
St. Cloud, FL
While Lia's appeal for additional personal care services was pending she lost ALL of those services! Her home health agency blindsided Lia and her family by informing them that the agency would no longer be providing personal care.
Three days after appealing her managed care plan’s denial of additional needed personal care hours, the home health agency informed Lia that they would no longer be providing personal care. The reason they gave was shocking: they were not licensed to provide this essential service which requires hands-on care with activities such as bathing and dressing. For the first time, Lia was told that this agency, which is part of her managed care company’s network of providers, is only licensed to provide homemaker and companion care services (which are not “hands on”). In spite of that, this agency had been providing Lia with daily “hands on” personal care services for months.
To recap: Lia, who is quadriplegic, needs 24/7 care and was already struggling to survive with only 34 hours of personal care approved by her managed care plan. Her family had already reorganized their lives and sacrificed greatly to help meet Lia’s urgent need for additional care. Her sisters from Illinois, New York, and North Carolina traveled to Florida to help take care of her. Another sister who lives in Florida and, thankfully, is a nurse, would drive over an hour several times a week to help with Lia’s care. Lia and her family were already forced to pay out of pocket for additional hours of personal care desperately needed and denied by her managed care plan.
And then, fast forward to Chapter 2: the home health agency stopped providing personal care altogether. According to Lia, they were concerned that her upcoming Medicaid Fair Hearing might have adverse consequences for the agency since they were not licensed to provide personal care. So they stopped coming. And there was no replacement for weeks– another violation of the plan’s contract with the Medicaid Agency. Under that contract, there should be a “Gap Plan” provided to each enrollee. Specifically, managed care plans are required to inform enrollees about their individual “gap plan” in which an identified back-up home health agency provides the services within 3 hours. Theoretically, this is how it is supposed to work. But that did not happen. After her unlicensed provider stopped providing personal care service, Lia waited 24 days (576 hours) for a provider.
As Lia said, "They [the health plan] make people like myself feel invisible. The lack of care for me has changed my life forever and my recovery is almost impossible."
After more than a year of fighting to get the services she so desperately needs, Lia and her family finally gave up on Florida. She moved to New York. Her sister Leslie explained: "I feel like she will get much better care in New York where they actually fund Medicaid."
Postscript: Ironically, right after Lia moved, counsel for Lia’s health plan informed FHJP that the health plan would be overturning their denial for the requested additional 56 hours of personal care. This came too late for Lia, and, as sister Lauren said: “what’s ironic is that even if they do authorize the hours, there isn’t a provider, so what good does it do?”
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