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Years atop waiting list, but still stuck in line

A mismanaged state medical program continues to eat funds, even as enrollment falls, a deposition says.

Published June 3, 2006

Vania Guarino doesn't need a nursing home. She needs an extra pair of hands around her house. Someone to help her bathe. Buy groceries. Get cash for the bus. And make sure she hasn't fallen, again.

Legally blind and forced to use a wheelchair, the Pembroke Pines 56-year-old has been told for 2½ years that she is near the top of a 3,100-name waiting list for a small state program designed to provide health and household care for low-income, disabled Floridians. The idea is to keep them out of nursing homes.

But nobody has moved off the waiting list in two years.

Even as enrollment in the program has steadily dropped, potentially freeing up dollars for new enrollees, no spots have opened in the program, called the Aged and Disabled Adult Medicaid Waiver for 18- to 59-year-olds. Enrollment in the program was down to 794 as of last week from 1,305 five years ago.

Where is the money going? Partly to pay rising health care costs for those already in the program, according to officials with state Department of Children and Families, charged with managing the Medicaid waiver. But it also goes to pay off a $1.5-million deficit accrued when the program was mismanaged, according to a deposition obtained by the Times.

In the deposition, a DCF supervisor recently said that the $1.5-million deficit accumulated sometime before 2004 due to a combined lack of oversight from three state agencies: his employer DCF, the Department of Elder Affairs and the Agency for Health Care Administration. However, his boss emphasized the responsibility was and is with the DCF.

In the big budget picture, the Medicaid waiver program for 18- to 59-year-olds is a minuscule part, a mere $12.5-million of the $1.3-billion to be spent on the developmentally disabled this year. But to a few thousand Floridians who have languished on the program's waiting list, the program is their ticket to a better life outside a nursing home.

"I'm a human being, not a number, and they're killing me little by little," said Guarino, who has a spinal cord disease and seizures. She's been hospitalized several times, mostly because nobody finds her soon enough after she suffers a seizure and falls out of her wheelchair.

DCF officials learned about the $1.5-million deficit about 20 months ago. Yet, the story of how it accumulated for so long, and without being noticed, is a bit complicated.

The Medicaid waiver program is jointly administered by the DCF, Elder Affairs and the Agency for Health Care Administration, the state's clearinghouse for all Medicaid programs. Elder Affairs oversees the part of the Medicaid waiver which helps those 60 and older, and the DCF manages the part of the waiver that helps 18- to 59-year-olds.

Yet, it was Elder Affairs, not the DCF, that had sufficient staff members to manage the waiver, said the DCF's adult services program director, Chris Shoemaker, in March. He was being deposed for an administrative complaint filed by Cory Baker, 22, of Lighthouse Point, who is also on the waiting list for the program. An attorney for Baker, who has a brain injury, filed a complaint last year against the DCF alleging that too much time spent on the waiting list violated federal Medicaid laws. (Baker's attorney recently dropped the complaint but declined to say why.)

According to an understanding between the two agencies, Elder Affairs was watching over the DCF's part of the waiver, Shoemaker said. Meanwhile, the DCF became "complacent" and appears to have dropped "any" oversight responsibility for its 18- to 59-year-olds in the program, Shoemaker said in the deposition.

In 2003, legislative auditors found accountability and oversight problems in the program, according to state records. That's when the DCF decided to take over responsibility for its part of the waiver program, according to Shoemaker.

That's also when the DCF discovered that nobody had checked to make sure that health care providers had been staying within their approved budgets over the years.

Moreover, the DCF wavier program for 18- to 59-year-olds had somehow been receiving and paying bills for more than 60 people who weren't in the program, Shoemaker said in the deposition. For example, health care bills for those on a different Medicaid waiver, one designed to help people with spinal cord injuries, were being paid by money meant to keep 18- to 59-year-olds out of nursing homes.

To make ends meet, program administrators had been using new dollars doled out each July 1 to pay unpaid bills from the past, Shoemaker said.

"We discovered to our amazement that there was a historical billing deficit issue," Shoemaker said. "No one in this department had brought it to our attention and raised it as a concern, much less had (elder affairs) raised it as a concern. They may not have known about it."

It's not clear who at any the three agencies is at fault for the deficit, and several agency spokesmen declined to answer questions, referring a reporter to a short letter DCF Secretary Lucy Hadi wrote May 26.

Hadi wrote a letter of apology to the heads of Elder Affairs and the Agency for Health Care Administration saying that Shoemaker had not intended to blame other agencies for the DCF's problems with the program. She also wrote that the "DCF accepts responsibility for this program and will continue working to improve the overall quality and integrity of this program."

DCF spokeswoman Zoraya Suarez would not elaborate on the apology or say if the DCF disputed Shoemaker's testimony.

The agency has since strengthened its accountability measures and is auditing a random 10 percent of clients each month to ensure that health care stay within budget, Suarez said.

The DCF also is reducing debt by using some of the dollars freed up when Medicaid waiver program patients drop out of the program, both Shoemaker and a DCF spokesman confirmed. Dollars free up when clients die, move out of the state, make too much money or become too old for the program. First, the DCF uses the additional money to meet the needs of those already in the program; the rest goes to the shortfall. So far, the DCF has paid off $500,000, about a third of the deficit, and has about $1-million left to go, Shoemaker said in the deposition.

However, that means no dollars freed from openings in the program have been going to move people, like Guarino and Baker, off the growing waiting list, which infuriates welfare advocates.

"Why are the clients of DCF being penalized for mismanagement?" said Southern Legal Counsel attorney Andrea Costello, who represented Baker. Despite these problems, about 500 needy Floridians might soon get some good news. The new state budget, which Gov. Jeb Bush approved last week, contains an extra $4.7 million to reduce the waiting list. That could make a 15 percent dent in the list, which had grown to 3,189 last week, up from 2,299 about two years ago.

It's the first increase in funding for the program in at least eight years, and it came after a Senate committee heard about the program and its waiting list for the first time in April.

"That's what's so distressing about this: We didn't know," said Sen. Nan Rich, D-Weston. "It was really a tragedy that these people were totally ignored."

The extra $4.7 million also came with a stipulation: it can only be used to reduce the waiting list.

[Last modified June 3, 2006, 06:06:11]

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