California-based insurance company Health Net's decision to cut assisted living benefits for low-income seniors has some advocates fearing those seniors may end up on the streets.
Families and elder-care advocates say Health Net's plan to end assisted living coverage for about 3,500 low-income seniors in California could jeopardize both the housing and the daily support many residents depend on.
Critics warn that for older adults with dementia or similarly high care needs, losing the benefit may trigger risky moves into hospitals, nursing homes, or other placements that are not suited to their care.
Here's what to know
Health Net, a major Medi-Cal insurer, says its assisted living benefit, which helps pay for 24-hour services in board-and-care homes, memory care facilities, and similar residences, will end Dec. 31, according to CalMatters. CalViva Health and Community Health Plan of Imperial Valley, which contracted with Health Net, are also affected, CalMatters reported.
Relatives say they have been left stunned and struggling to get clear answers.
According to CalMatters, Matt Johnstone learned that the North Hollywood home caring for his 89-year-old father may no longer be able to keep him there. Johnstone said his father has dementia, and without help from insurance, the family cannot cover the roughly $6,000 monthly bill.
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CalMatters reported that Health Net, in an unsigned statement, said members would keep receiving care until their authorization periods end and could be moved to nursing homes, in-home care, or other programs.
"We are working closely with members, providers and care management teams to develop individualized transition plans based on each member's clinical needs and eligibility for other available programs and services," the statement said.
Advocates say that reassurance falls short. Pauline Shatara, deputy director of California Advocates for Nursing Home Reform, told CalMatters: "This is going to be a disaster."
More background
The benefit is part of CalAIM, California's Medi-Cal overhaul, which was designed to improve care while cutting repeat emergency room visits and expensive hospital stays.
Monthly assisted living costs generally run from $5,000 to $7,000, while nursing home care can exceed $10,000.
In filings to regulators, Health Net said the program "has not led to better care" and argued that it was bringing more people from home into assisted living instead of moving residents out of nursing homes into lower-cost settings.
Advocates say Health Net's rationale ignores patients' needs and treats vulnerable seniors chiefly as a financial calculation.
Hagar Dickman, director of long-term services and supports for Justice In Aging, said: "Their position is it's less costly to offer no services than some services."
Families describe the rollout as chaotic as well. Jennifer Horcasitas-Glenn told CalMatters that when she called about the coverage used by her 75-year-old mother-in-law, Jacqueline Glenn, who has dementia and Alzheimer's, customer service representatives often did not understand which program she meant.
What's being done?
According to CalMatters, state regulators say Health Net members can keep services through Dec. 31 if the care remains "clinically appropriate," and people whose approvals expire before Dec. 31 may ask for an extension. The Department of Health Care Services has also said it will communicate with Health Net to "ensure member protections and continuity of care."
Advocates question whether those measures will truly protect residents.
Patients are supposed to get 30 days' notice, can pursue grievances or appeals, and may qualify for other services. But those steps do not guarantee the same level of support in a different setting.
Some families are looking at other Medi-Cal plans that still provide the benefit, though advocates told CalMatters that new enrollees can have a hard time getting approval for costly long-term care. Others are trying to find out whether services could stop after Oct. 7, when some provider contracts expire, even though benefits are supposed to continue through Dec. 31.
Johnstone described the uncertainty many families are now facing. "He's declining, and I just don't know what's going to happen if the program ends," he said.
Shatara was even more direct: "It's inevitable that people will end up in ERs and on the streets."
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