Advocacy group to share concerns about KanCare grievance process

Kansas Advocates for Better Care seeks ‘good data’ on whether Medicaid beneficiaries are getting services they need

By Dave Ranney, KHI News Service, August 20, 2015

Each month, according to the latest available data, roughly 225 KanCare beneficiaries file complaints about the care they’ve received or been denied.

That’s a small percentage, considering that more than 400,000 Kansans depend on the state’s privatized Medicaid program.

The numbers also show that all but a handful of the complaints are resolved within 15 days. State officials often cite the data when assuring legislators that KanCare, now in its third year, is meeting the needs of its beneficiaries.

Mitzi McFatrich isn’t so sure. The numbers, she said, are “pretty vague,” noting that few complaints don’t necessarily mean that Medicaid enrollees are getting the services they need.

McFatrich is executive director of Kansas Advocates for Better Care, a nonprofit organization that lobbies on behalf of frail seniors, nursing home residents and their families.

She said a complaint being “resolved” means different things to different people.

“We just don’t have good data when it comes to assessing how things are going,” McFatrich said.

Many KanCare beneficiaries, she said, are still figuring out how the new system works because the case managers who would have helped them file complaints in the past have been replaced.

Before KanCare, Kansans with disabilities on Medicaid had case managers that worked for advocacy groups in their communities. Now their care is coordinated by case managers who work for one of the three private insurance companies that administer KanCare.

“People are pretty much on their own now,” McFatrich said. “We’ve had consumers tell us their case managers discourage them from filing appeals or grievances because if they lose, their services will be cut even more.” 

McFatrich is expected to share KABC’s concerns with the Robert G. Bethell Joint Committee on Home and Community Based Services and KanCare Oversight, which meets at 9 a.m. Friday at the Statehouse.

KABC last month published and began distributing “KanCare and Your Plan of Care: Know Your Rights.” The eight-page guide is designed to help beneficiaries understand the process for filing complaints with the insurance company handling their case or with the Office of Administrative Hearings within the Kansas Department of Administration.

“We just feel like it’s important for Medicaid beneficiaries to understand that they have rights and that there’s a process for disputing decisions that affect the level of care they receive,” McFatrich said.

The guide’s costs were underwritten by grants of $7,000 from the REACH Healthcare Foundation and $1,000 from the Legacy of Justice Foundation.

The processes outlined in the guide apply to frail seniors as well as people with physical and developmental disabilities.

“People are not always getting the services they need,” said Chris Owens, who runs the Prairie Independent Living Resource Center in Hutchinson. “They’re having their hours cut, but they either find it difficult to file an appeal or they’re uncomfortable doing it, and they just let it go.”

The Hutchinson facility is one of 10 Centers for Independent Living in Kansas that provide services to help people with disabilities live independently. Many of the centers’ employees are disabled.

“It’s a good thing to have this guide out there,” Owens said. “People need to know.”

In Kansas, roughly 8,800 people with developmental disabilities, 3,800 people with physical disabilities, 18,000 frail elders and 20,500 nursing home residents are on Medicaid.

KanCare beneficiaries who think they’re being denied the services they need to live in community-based settings have the option of asking the insurance company overseeing their care to take a second look at their care plans or to restore whatever cuts in services they’ve proposed.

If they’re dissatisfied with the quality of care they are receiving, beneficiaries may file a grievance with their KanCare company.

More than 95 percent of these appeals and grievances, according to quarterly reports compiled by the Kansas Department of Health and Environment, are resolved within 15 days of being filed.

But that doesn’t mean decisions about care plans were reversed or that services were restored. It only means they were reviewed.

Sara Belfry, a KDHE spokesperson, said each KanCare company “defines a grievance differently.”

Still, Belfry said, the process provides an accurate measurement of how well the companies are meeting beneficiaries’ needs.

KDHE, she said, encourages KanCare beneficiaries to work with their care coordinators and to make themselves heard.

Those who aren’t satisfied with their KanCare company’s response can request a “state fair hearing,” during which an administrative law judge will hear the evidence and render an opinion.

Between July 2014 and June 2015, 185 KanCare grievances were filed with the Office of Administrative Hearings. Of these, 32 were denied; three were upheld; two were modified; 126 were dismissed or withdrawn, usually due to agreements reached outside the hearing room; and 22 are pending.

The processes, McFatrich said, are difficult to navigate, especially for people with disabilities.

“There’s no one in the system who advocates for them,” she said. “They can call the KDADS ombudsman’s office and they’ll try to answer their questions and they’ll tell them who to call, but they’re not allowed to advocate for them. They can in other states, but not in Kansas.”

The nonprofit KHI News Service is an editorially independent initiative of the Kansas Health Institute and a partner in the Heartland Health Monitor reporting collaboration. All stories and photos may be republished at no cost with proper attribution and a link back to when a story is reposted online.

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