Medicaid in-home care client fears losing independence with low rates

Robin Zehntner, 31, doesn’t have the use of her fingers, and caregivers help her 31.5 hours a week with morning tasks such as brushing her teeth or getting into bed in the evening.

“I kind of live in daily fear because, will I be able to get out of bed tomorrow?” said Zehntner, of Missoula. “Small things for other people are big deals for me.”

Through Medicaid, she can pay an hourly rate of $13.10 for help, and Zehntner can’t remember the last time the pay went up. Recently, one of her two caregivers finished graduate school and took another job, a development Zehntner said was expected but also stressful.

“I’ve been worried for months because I knew this time was coming,” said Zehntner, who is a quadriplegic. “ … I also saw the cost of living going up, and everyone demanding higher pay, and I guess I was always hoping that we would follow suit, or that everyone would … start paying workers more.”

A study commissioned by the Montana Department of Public Health and Human Services recommends increases in Medicaid reimbursement rates. Dated July 2022, the report generally said Montana needs another $82.4 million to reimburse providers at recommended rates and consider growth in services.

The report puts the current cost at $375.5 million and the recommended benchmark at $458 million, or 22 percent more.

Most of the additional money would come from the federal government, said the report by Guidehouse, which bills itself as an industry guide through complexity. Of the total new dollars recommended, the state would need to put in $27.7 million, and the federal government would cover the rest, based on the report.

However, any change is still nearly one year away. DPHHS noted the Montana Legislature will make decisions about Medicaid during the 2023 legislative session, which doesn’t start until January. Plus, changes typically wouldn’t take effect until the following July.

In the meantime, Rep. Marilyn Marler, D-Missoula, said more and more people are opting for in-home care, which she believes is a better model. The report too notes in-home services are expected to grow significantly.

But Marler, who noted she’s not on the health and human services committee, said people like Zehntner have trouble hiring workers because the payment is so low, and for some, the situation is becoming impossible.

“This is a crisis,” Marler said.

Rep. Ed Stafman, D-Bozeman, served as chairman of the Children, Families, Health and Human Services Interim Committee, and in July, the committee sent a letter to Gov. Greg Gianforte.

The letter was focused on the deterioration of the mental health care system, but it also asked the governor to take action on rates prior to the start of the next fiscal year, July 1, 2023.

“Based on the Guidehouse presentation and the work we’ve done this interim, committee members agreed to ask that your administration review potential funding sources that would allow the Department of Public Health and Human Services to raise Medicaid reimbursement rates now, rather than waiting until the next biennium,” said the July 18 letter.

The letter said the committee, which has since completed its work, was hopeful the administration would be flexible and possibly look at the ending fund balance, marijuana taxes, or American Rescue Plan Act funds for additional money (the last to be used to support mental health).

The Daily Montanan asked the Governor’s Office and DPHHS about possible increases prior to the 2023 session and received a response from  DPHHS. In a statement, DPHHS spokesman Jon Ebelt said the Montana Constitution puts appropriations authority in the hands of the Montana Legislature, and if the Legislature wanted the agency to increase any rates in advance of July 1, 2023, it would have to provide an appropriation.

But he said DPHHS isn’t budgeted to do so.

“The reality is the Legislature has not authorized additional funding for DPHHS to address Medicaid provider rates at this time,” Ebelt said in an email. “DPHHS is currently working with rates that were set by the Legislature and must be adjusted by the Legislature.

“The administration has been clear about its intentions to address rates in collaboration with the Legislature, and will continue to use its recently completed provider rate study to inform related budget requests for the next biennium.”

The study, called Montana Rate Studies, offered recommendations for new rates reimbursed by DPHHS for a series of programs and services, including Senior and Long Term Care. The exhaustive review notes a peer comparison among other states did not find systematic underfunding in Montana, but it did note Senior and Long Term Care show “slightly lower overall rates than the state averages.”

Rose Hughes, executive director of the Montana Health Care Association, said generally, the study has shown the rates the state pays for services is “significantly lower than what they should be.” In an email, she also said it is notable that the division that is most underfunded is Senior and Long Term Care. The Montana Health Care Association represents skilled nursing facilities, including nursing homes.

The report said senior- and long-term care rates have the farthest to go to achieve “rate adequacy,” with a recommended 29 percent increase compared to 22 percent increases for services as a whole. As for care at home, Hughes said it’s part of the continuum of care, along with assisted living facilities and nursing homes.

“All three of these services are important to our frail elderly Montanans, and all three are significantly under funded by Montana’s Medicaid program,” Hughes said.

Zehntner is not elderly, but she does use care at home, and the report discusses that service. For example, it notes in part that “self-directed” services can incur 20 percent less administrative costs than agency-based services.

One recommendation notes rates for services such as personal assistance and care increase 50 to 70 percent to keep up with growing labor costs.

“These services should be prioritized for reimbursement to sustain supports for care delivered in home settings,” said the report, 186 pages in all.

Even if it’s adopted, the recommended increase wouldn’t necessarily translate into an automatic 50 percent bump in the hourly rate Zehntner pays, according to DPHHS. DPHHS noted the recommendations are comprehensive, and it can’t confirm a direct correlation between adopting the full rate and specific worker’s wages.

Zehntner, however, believes the translation may mean she could advertise a job at $16.66 an hour. In her most recent round of hiring, which she does through “employer of record” Summit Independent Living, her remaining worker decided to take on the extra hours after her other employee gave notice.

“My current gal is ready to do 31.5 hours a week,” said Zehntner, who was in an accident at age 17. “But I also know that she has a life outside of me, and I care about her and don’t want her to work too hard for me, especially where she has bills to pay, too.”

Zehntner has a degree in literature and creative writing from the University of Montana and another bachelor’s in graphic design. She said the help she gets may not seem like a lot, but it’s significant to her; she has the use of her arms for the most part, but not her fingers.

Now, she wonders if next time a worker quits, she’ll be able to rehire. Sometimes, she continues to worry. 

“Tonight, am I going to go to bed? I’ve only ever had one person call a no-show,” she said. “Luckily, I was able to get a hold of a friend of mine, but am I going to be sleeping in my wheelchair tonight? Luckily my friend just happened to be awake and helped me into bed.”

In an emergency, she could move in with her family, but they’re in White Sulphur Springs, and she’d like to remain independent.

She said this too: “It’s not fun living in fear of just trying to live your life.”

Editor’s note: The Daily Montanan has added the attached letter below provided by DPHHS to this story.