Hi Trish, Have you tried WheelchairJunkie.com or SCI-Cure? Best Wishes In a message dated 10/2/2012 12:55:32 A.M. Central Daylight Time, [email protected] writes:
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!
