66-year-old Esfandiar Asbagh is waiting to learn if he is eligible for state adult day care services. (Mina Kim: KQED)

Golden State Adult Day Health Care in San Francisco serves seniors primarily from Russia, Ukraine and other Eastern European countries. As I walked in, I saw immediately that I was underdressed. All around were seniors pushing walkers, and they were wearing glittering sweaters, fur hats or chiffon skirts.

“This is mostly clothes from fifty years ago,” Center Director Katya Hope says. “But you look like you’re going to the opera because in fact, this is the major chance to socialize.”

Socializing is why 83-year-old Berta Vekhman says she loves it here.

“We cannot stay alone. When we are alone, we are dead,” Vekhman says. “because we stay alone and nobody at home you cannot talk to somebody. You forget how to talk.”

Vekhman suffers from diabetes, Parkinson’s Disease and needs help using the bathroom. She is prone to depression which she says has worsened since January. That’s when state officials deemed her — and 2,000 other seniors — ineligible for services.

Vekhman was receiving care through the Adult Day Health Care program. Through the program, independent centers, like Golden State, provided physical therapy, mental health treatment and a chance to socialize.

In a budget balancing move last year, Gov. Jerry Brown tried to eliminate Adult Day Health Care entirely. But advocates for the disabled sued, and the result was a legal settlement that created Community Based Adult Services. It’s a smaller program and has stricter eligibility requirements.

Vekhman has appealed her ineligibility.  She feels lucky that Golden State is letting her continue to come for free. But the prospect of being home alone is hard on her. “I cry all day, all day,” she says.

According to attorney Alice Ho the state is rejecting people who clearly qualify for the program. Ho and her colleagues at the law firm Ropes & Gray have handled the appeals of 14 of the seniors at Golden State Adult Day Health Care.

“These seniors had either Alzheimer’s or another form of dementia, issues like Parkinson’s disease, coronary artery disease, spinal meningiomas, other tumors,” Ho says. “Imagine older grandparents who’ve actually gotten really sick.”

What frustrates Ho is that all 14 seniors had initially been deemed eligible after face-to-face evaluations with state nurses last year. Officials with the Department of Healthcare Services overturned the nurses’ assessments, creating a lengthy appeals process — that has resulted in all the seniors getting reinstated.

Golden State Adult Day Health Care has managed to keep providing services to seniors, even though the state is not reimbursing centers during the appeals process. But that’s been the exception, not the rule.

At Grace Adult Day Health Care in Sunnyvale, an occupational therapist leads seniors through stretching exercises, giving instructions in both English and Farsi. At this center which serves seniors — mostly from Iran and Afghanistan — the state deemed nearly 80 of them ineligible for Community Based Adult Services.

“That’s almost half the center,” Grace Adult Day’s director Manooch Pouransari says. “And we think all of them are a mistake.”

The seniors here filed appeals earlier this year, but the state hasn’t yet decided any of them. Pouransari says he tried to swallow the costs of caring for these seniors, but after three months, it became too much.

“It was a big blow financially to keep them here without the pay.” Pouransari says. “But with the state not responding, no news about hearings, we had to let them go.”

Pouransari says the seniors have suffered strokes, falls and broken hips.

Esfandiar Asbagh, 66,  says he’s had several falls while he’s been home alone. Asbagh was stricken with polio as an infant and can’t control the left side of his body.

“I have dizziness,” Asbagh struggles to say. “I’m very deep depression when I am alone.”

Asbagh says what keeps him going is the belief that the state will allow him back in to the program. “I believe 95 to 95 percent I’ll win.”

State officials say delays in the appeals process stem from the program’s legal battles and that the agency is now moving through the cases much faster. They say hearings are expected to be completed next month. Jane Ogle, Department of Health Care Services Deputy Director, says she stands behind the agency’s eligibility determinations, including the ones that have overruled nurses’ earlier assessments.

“With such a highly scrutinized program, we need to make sure that our decisions are fair and accurate and correct for each of the participants,” Ogle says. “That’s why we put in a quality assurance review for each of these decisions”

On November 8, state officials are expected to explain this in federal court. Advocates for the disabled say the state’s eligibility reversals are illegal and are asking a judge to order that all seniors awaiting hearing decisions be reinstated.

(Photo: Kaiser Health News)

After more than a year of battling over eliminating and then restructuring adult day health care coverage for Medi-Cal beneficiaries, California’s budget for delivering that care is similar to what it was before all the haggling started.

The Community-Based Adult Services program grew out of a lawsuit challenging the state’s proposal and replaces the Adult Day Health Care program. CBAS will provide services to 80 percent of previous ADHC beneficiaries and is funded at a similar level to the original program.

“The original budget for ADHC was $170 million, and the current CBAS budget is

Of course, that doesn’t count the expense of legal battles, or the daunting number of man hours spent designing and implementing a new system, not to mention the constant arguing and debating over more than a year, she said. Missaelides sighed at the idea of it.

“I guess I just don’t understand,” she said, “why we had to go through all of this.”

The ADHC-to-CBAS metamorphosis — which began in budget proposals more than a year ago — sparked legislation, multiple hearings at the Capitol and a lengthy lawsuit.

“We are in the process of implementing a legal settlement of substantial scope, and we are starting an entirely new program — two very costly activities,” said Norman Williams, deputy director of public affairs at the Department of Health Care Services. “Because of this, in subsequent years we expect additional savings to be realized.”

The state’s costs related to the lawsuit and settlement are separate from CBAS expenditures.

Process Slowing Down

DHCS recently announced it would phase in its new adult day health program, rather than implement it all at once on July 1. The shift involves several complicated steps: determining eligibility for 40,000 frail and elderly patients across the state, moving 80 percent of them to managed care plans and converting existing centers to not-for-profit status. The state recently adjusted its timetable and built in a three-month cushion to ease the transition.

State officials said 31 of the 253 adult day health care centers in California will make the switch in July, while the bulk of the centers now are eyeing an Oct. 1 deadline.

The extra time was necessary, health officials said, to work out a number of crucial details. For instance, the state requires any for-profit adult day health care center to switch to not-for-profit status to qualify as a Community-Based Adult Services center. But here we are — just about a month to the July 1 deadline and the state has not yet issued guidelines for that requirement.

In addition:

• Rates still need to be worked out for health plans
• Questions remain about what will happen if the for-profits can’t make the switch
• And what about patient eligibility denials?

Appeals to denials will be heard starting next week. The Adult Day Health Care Association recently announced that it will file an appeal to reverse the state’s 10 percent provider rate cut. Meanwhile, two more ADHC centers recently closed.

The good news for adult day health care beneficiaries is that state officials agreed to spend more on the new program. In the May budget revision, the CBAS budget was raised to $156 million for the next year.

Missaelides said state officials clearly have been listening to stakeholders’ concerns these days, as evidenced by the decision to delay implementation for most of the centers, with the new phase-in approach.

The relative handful of CBAS centers that will lead the way with a July 1 implementation date were selected because they are all County Organized Health Systems, according to Jane Ogle, deputy director of the Department of Health Care Services.

“We picked the COHS counties first because the beneficiaries are already members of the plan and don’t have to make a plan selection,” Ogle said. “This eliminates one step in the process.”

In the rest of the counties, a big step in the process will be enrollment into Medi-Cal managed care plans. Medi-Cal is California’s Medicaid program.

“In those counties where beneficiaries have to make a choice,” Ogle said, “we will wait until October, to give them plenty of time to make that selection.”