Vicki Stanford loves the days when she gets to attend Still Waters Adult Day Center. At the Indianapolis facility, the 81-year-old paints, attends tea parties and presses flowers but, more importantly, she gets to socialize with “people just like me.”
“There’s so many friendly people and it’s better than sitting at home and watching TV,” Stanford said. “We don’t do the same thing all the time.”
But Stanford’s two daughters, her caregivers, can only drive her to Still Waters from her Anderson home twice a week since Medicaid stopped paying for transportation services to adult day centers in July when the state transitioned to managed care, otherwise known as PathWays. For facilities that provide their own transit services — which doesn’t include Still Waters — the state stopped reimbursing transportation back in April, according to providers.
Terri Rinker, Stanford’s eldest daughter, and her sister both work full time. In addition to the wheelchair and diabetes management care Stanford needs, she also has short-term memory issues related to a traumatic brain injury after she went into cardiac arrest and collapsed more than two decades ago.
“My sister and I work hard to have people come over and visit … but it’s lonely for older people. It really is,” Rinker, 62, said. “I can’t say enough about Still Waters. They are happy and upbeat and positive and encouraging. And the things that mom would have enjoyed talking about, learning about and doing before her brain injury — they’re doing it now. And they’re just so good to her.”
“She has something to contribute to the conversation, even though she may not remember all of what they did,” Rinker continued. “Whatever it is, she has something to talk about.”
Now, Rinker drives from her home in Noblesville to Anderson to pick up her mother from her sibling’s home. Then she drives Indianapolis — where she works — to get Stanford to Still Waters. In the hopes of getting that transportation restored, the family has decided to switch their managed care coverage from Anthem Blue Cross and Blue Shield, the entity they were assigned to, over to United Healthcare Community Plan.
“We’re kind of taking a shot in the dark. But I don’t know what else to do,” Rinker said.
When asked about what she does at home when she can’t come to Still Waters, Stanford — a people person who volunteered with the Red Cross even after her brain injury — summed up her days in one word.
“Nothing.”
Statewide issues with transit services
Laura Altenbaumer, the president of the Indiana Association of Adult Day Services, knows of at least one center that closed partially due to the lack of transportation reimbursement — her own.
Altenbaumer oversees a chain of adult day centers with Active Day in Indiana and Illinois and said the company closed its northwest Indiana location in June. It still operates its two centers in Fort Wayne and Merrillville.
Laura Altenbaumer, president of the Indiana Association of Adult Day Services (Provided photo)
“It was a center that was struggling for utilization anyway and then with the compounded transition, (Medicaid) waitlist and transportation non-payment — it was just too much. Even as a large organization, we just couldn’t continue,” Altenbaumer said.
She said two more of the roughly 40 adult day organizations in the state reported that they might have to close their doors due to the above issues.
Altenbaumer estimated that between 60-65% of adult day centers provide their own transportation while others, like Stanford’s Still Waters, don’t directly employ drivers. At Still Waters, families of the facility’s “guests” previously received a referral to a Medicaid-approved transportation company with drivers trained to manage patients with dementia or memory issues.
“We had been utilizing a service that would come and pick up our guests and (the driver) was able to pick up any of my Medicaid guests because she was under the Medicaid waiver. She had been doing it for the last year and a half — picking up the same guests at the same time, same everything. Guests with dementia need that consistency,” said Diana Keely, the director of Still Waters.
The Family and Social Services Administration (FSSA), which oversees both the state’s Medicaid plan and Medicaid waiver services said the two programs both have separate transportation processes for non-medical transit. Under the state plan, non-emergency medical transportation is reimbursed by transportation brokers — Anthem uses WellTrans while Humana Healthy Horizons and United use LCP Transportation — while waiver services for non-medical transportation are billed to the managed care entity (MCE) by a provider.
“MCEs have an open provider network so there is no requirement for adult day service providers to contract with the MCEs to be paid. The MCE must pay the nonmedical transportation provider at or above the Medicaid waiver rate set by the state. The MCEs cannot deny nonmedical transportation if it is a service identified on the individual’s approved service plan,” said Michele Holtkamp, FSSA director of communications.
She added that non-medical transportation services “are the same” under PathWays and the pre-July 1 waiver, known as the Aged and Disabled Waiver, and there was no change “to the service or the service definition.”
In the coming week, the Office of Medicaid Policy and Planning (OMPP) will be releasing a bulletin to spell out differences between the transit services under the state Medicaid plan versus the Medicaid waiver, FSSA’s statement the Indiana Capital Chronicle continued.
“Furthermore, OMPP has communicated directly with the MCEs on their responsibility for covering nonmedical transportation when it is a service approved on an individual’s service plan,” the email concluded.
Still, both Keely and Altenbaumer reported problems with the transportation services utilized by the managed care companies, such as sending a non-accessible vehicle to pick up someone in a wheelchair, missed pickup appointments, drivers without dementia training or abandoning an elderly passenger who took too long to use the restroom.
For the programs with their own transit services, Altenbaumer said that reimbursements have been denied for all adult day providers since July 1, even though the bills are going through the managed care claims process successfully.
Issues like these are being funneled to a claims work group composed of providers and the three managed care entities. Altenbaumer is part of that group but worries that “my voice for adult day is not as loud as maybe assisted living (facilities) and long-term care.”
“I will say that (Indiana’s Division of Aging) is listening to providers and trying to make the necessary changes. I think it’s because all of the changes are happening and affecting such a huge group of providers — it’s kind of hard to prioritize,” Altenbaumer said. “… I think the state is attempting and trying to fix that for providers and find a solution for providers, but I think because of the overwhelming issues within claims process, they’re not being addressed as quickly as we had hoped.”
Both Altenbaumer and Keely reported few issues with submitting claims for the services they provided as adult day centers — saying transportation has been the bigger hurdle.
Adult Day Services a beacon for some
Keely shared her own caregiver story with her father when talking about the important role adult day can play in someone’s life. He attended a center for three years before the COVID-19 pandemic, which shut down facilities statewide.
He died just six months later, before Keely started her own career in adult day services at Still Waters.
“No matter what I did, it just wasn’t the same. They don’t have the social engagement,” Keely said about her father’s time at home during COVID. “I feel like I want to be an advocate for my families (at Still Waters) — finding resources and finding what they need. The majority of families who come into the situation of being a caregiver don’t know how to do it; that’s what happened with my dad.”
Keely said the center invites families of their guests to attend monthly sessions on elder care topics. Last month, someone from Indiana University talked about healthy aging and next week someone from the Attorney General’s Office will talk about scams targeting Indiana’s seniors.
Something repeatedly said in meetings with providers and the public by state officials was that, for the first 90 days after the managed care transition, families would experience no changes in their coverage, their providers or their services.
“(Guests) were told, we were all told: ‘The first 90 days, nothing will change. Whatever service you had, you will continue having,” Keely said.
FSSA’s website says that authorized Medicaid services will continue to be covered for 90 days and that the managed care companies would have to have “open networks” that include all providers who want to contract with them.
“You will continue to receive the same Medicaid benefits in the PathWays program,” the site reads.
That claim feels hollow to Hoosiers like Rinker.
“It’s been six weeks and we can’t talk to anybody. Nobody returns our calls,” Rinker said.
Instead, calls to Anthem came to confusing conclusions, pointing to Stanford’s home health hours at the family’s preferred company and saying they needed to switch providers. Or saying that transportation and home health needed to be covered by the same company. Repeatedly, customer service and managers said that they don’t transport to adult day centers — though adult day transportation is one of the three types of non-medical transportation supposedly available under managed care for Medicaid waiver enrollees.
“If I have to pick and choose between, ‘Do I stay up with mom so she doesn’t fall and I can administer her insulin and I not sleep all night?’ Or, ‘Do I spend a couple hours driving her to Indianapolis?’ I’ll choose to transport,” Rinker said.
Rinker readily admits that the family’s situation “wasn’t great before” the state’s transition to managed care, but said she had a case manager who knew her mother and recommended resources.
“She came to the house … (and) if you would just mention, ‘Mom’s not eating very well and she’s losing weight.’ She would say, ‘You’re eligible to receive nutritional supplements. Let me arrange to have those shipped to the house,’” Rinker said.
Rinker openly wondered who benefitted from the managed care rollout, saying, “I don’t believe for one minute that they changed to for-profit insurance companies and that those insurance companies can provide the same services and make a profit.
“I don’t see Anthem saying, ‘Oh, we can ship you nutritional supplements because you mentioned your mom is not eating well and losing weight.’ Because that’s going to cost them money,” Rinker continued. “What were you thinking, state government?”