My friend, a resident of a subacute facility, is a spastic quad with a
trach. He cannot speak. He has no means to signal if he is undergoing
respiratory distress. Finally, he has gotten appointments for
occupational and speech therapy at a rehab center which is in the top 20
nationally. So we have hope. The problem is his facility is 45 miles
away from the rehab center and his facility’s social services director
is saying neither Medi-Cal nor Medicare will pay for transportation. We
could take public transportation for the disabled but. . .
--- He could require suctioning enroute. While his mother could
administer shallow suctioning (with a Yankauer), the set up of the
public disabled transport isn’t conducive to this since 1) the
wheelchair is positioned next to the driver where she would have no
access to her son. And 2) we may be accompanied by other riders.
--- He has no good anterior head support if he must be seated
vertically, in his wheelchair
--- The trip one-way can take 2 ½ hours instead of the 1 hour it would
take by a non-emergency ambulance. Since he has a G-tube, that 5 hour
round trip and 2 hours of appointments means he has no food or water or
meds at least 7 hours.
Are any of you familiar with Medi-Cal or Medicare regulations?
--- Medicare - As I understand it, all Medicare non-emergency medical
transportation (NEMT) requires that there be a medical necessity. Isn’t
it a medical necessity that my friend be able to signal he needs help if
his trach becomes plugged?
--- Medi-Cal I think has the same requirement. They will pay for NEMT if
there is a medical necessity so I would apply my Medicare argument here
too. But also I read that there was a legal case (Valdivia v. Coye)
which required Medi-Cal to expand eligibility to include therapy
services when they’re deemed necessary for a nursing facility resident
to attain or maintain the highest practicable physical, mental or
psychosocial functioning. For my friend, OT & ST could do so much to
help him toward this goal. Since he has basically been treated as a
custodial case so far, does the fact that the rehab center recognizes
his potential mean that Medi Cal should provide him means to get to
those appointments?
Do you know of any precedent for such a case or maybe you have an
example of a successful Medi-Cal Task Authorization Request that I could
show his facility’s Social Services Director. Do you have know of a
medical transport company in the Metro Los Angeles area that might take
on such a case pro bono or at a significant discount?
Thank you for your help.
Trish
P.S. If not, perhaps you know of a forum where folks might have answers
for us? Thanks!
