PROVIDENCE – The online portal to sign up for Medicaid long-term care services does not yet work. It has not worked since being introduced on Sept. 13, the date when the launch of the $364 million Unified Health Infrastructure Project, known as either UHIP or RI Bridges, went live.

[There had never been an online portal before; UHIP was supposed to introduce one, but it has never functioned properly.]

Attempts to correct the problem, working with Deloitte, have proven unsuccessful to date, according to sources. Nursing home advocates were told a month ago to stop trying to use the online portal and that a fix was being developed.

In the meantime, Sophie O'Connell, spokeswoman with the R.I. Executive Office of Health and Human Services, told ConvergenceRI on Nov. 25 that nursing homes are being encouraged to send the application information for patients requesting Medicaid long-term care services directly to R.I. Department of Human Services, where agency workers can then input the information into the system.

This latest glitch and work-around would no doubt be considered big breaking news – save for the fact that ConvergenceRI reported on the problem a month ago, in its Oct. 24 newsletter: “Who is responsible for the UHIP snafu? Legislators demand answers.” [See link to ConvergenceRI story below.]

In that story, as ConvergenceRI reported: One apparent UHIP glitch that has yet to make the news or to be shared with legislators is the failure of the online application process for long-term care coverage under Medicaid for patients in nursing facilities.

Since UHIP went live on Sept. 13, many nursing facilities, working on behalf of their patients, have attempted to sign up for long-term care coverage, carefully following the instructions, according to Virginia Burke, president and CEO of the of the Rhode Island Health Care Association.

“Facilities have been trying for a couple of weeks, following instructions, going to the portal, but so far, no one’s being able to do it,” Burke told ConvergenceRI.

On Friday, Oct. 21, Burke received an email from an agency official confirming that the online application doesn’t work, telling Burke to tell her members to stop trying to use it, saying that EOHHS was working to develop an interim process.

The glitch is especially worrisome, Burke continued, because the backlog of pending cases keeps growing for the agency to make a determination whether Medicaid will accept the application for long-term care. Until a determination is made, the nursing facilities provide care without compensation.

If the application is approved, payments are made retroactively. If not, the facilities have to eat the costs as uncompensated care. Decisions are supposed to be made in a timely manner, but the backlog in the last year has often stretched from six months up to a year.

Since the implementation of UHIP on Sept. 13, the backlog of pending cases has grown, according to Burke. “Facilities are already carrying an intolerable burden of uncompensated care,” she said. “They are obviously and understandably worried that this new system is going to make things worse.”

Behind the curtain of the backlog
Last week, the fact that nursing homes were facing enormous financial burdens from uncompensated care for Medicaid patients because of delays by the state in approving or rejecting the long-term Medicaid applications finally broke through the mainstream news barrier, with WPRI’s Susan Campbell reporting about two nursing homes that were carrying balances as much as $1 million, awaiting determinations from the government.

The story, given the full breaking news treatment, may come up, no doubt, at the second hearing of the Joint House Finance Committee and House Oversight Committee scheduled for Monday, Nov. 28, in Room 325 at the State House, beginning at 3 p.m.

It is an important story, one that, once again, ConvergenceRI first began reporting on three months ago in its Aug. 29 newsletter, following the news briefing by the R.I. Department of Human Services and the R.I. Department of Administration to announce planned layoffs in advance of the implementation of UHIP.

As ConvergenceRI then reported: For many nursing facilities and home care providers in Rhode Island, the new system is being viewed with great trepidation and the layoffs seem premature.

A deeper worry is how the new system will impact Rhode Islanders currently receiving nursing home care – after a heart attack, a stroke or hip surgery – that have lost their Medicare coverage and need to apply for Medicaid services.

The nursing facilities then provide services without compensation while the application is being processed. A decision is supposed to be made within 30 days, but lately the determination can often take months. Even if the facility receives a retroactive check months later, the process can play havoc with a facility’s cash flow.

The financial burden placed upon nursing facilities awaiting a decision on Medicaid eligibility can be severe. As a number of sources told ConvergenceRI, the funding stream for Medicaid payments from the state has reached a crisis level.

“Nursing facilities are already financially fragile, due to their heavy Medicaid census. The state today owes millions to these facilities whose Medicaid applications are dragging on. If it gets worse some will have difficulty making payroll,” one source said.

At the same time, the home care agencies are experiencing great difficulty in finding workers because of low reimbursement rates from the state.

Human expertise
The layoffs were also worrisome because it appeared that some of the human expertise needed to navigate the complex application for long-term services under Medicaid would be leaving.

Once again, as ConvergenceRI reported three months ago: Yet, for some advocates, particularly those involved with long-term care and nursing homes, the layoffs a month in advance of implementation raise serious concerns.

More than, say, a changeover to online banking services and the resultant layoff of bank tellers at neighborhood branches, the new system may create its own set of worries and problems, particularly for long-term care patients [and their caregivers] attempting to negotiate the complex application process for Medicaid services, particularly for patients that may be suffering from dementia and have behavioral health care issues.

“Why not implement the new program, and have it up and running and working appropriately, making sure that that all the bugs are worked out, before deciding how many staff can be assigned elsewhere,” one nursing home advocate asked. “To do it a month before you’re going to implement this new program doesn’t make any sense.”

The workers who know best how the system works won’t be there to fix the problems encountered by customers.

What did you know, and when did you know it?
Much of the focus of the Nov. 28 hearing promises to be on the problems identified by the regional Boston office of the federal agency, Food and Nutrition Service, responsible for overseeing the Supplemental Nutrition Assistance Program, or SNAP benefits.

In a letter dated Nov. 8, which became an election night news dump from the R.I. Department of Human Services, FNS Regional Administrator Kurt Messner demanded that Rhode Island submit a corrective action plan or face the loss of federal funds.

“Our goal is to help DHS avoid suspension or disallowance of administrative funding and ensure access to SNAP from eligible households in Rhode Island as well as the integrity of the program,” Messner wrote.

In response, state officials submitted its “corrective action plan” on Nov. 22 to FNS, along with more precise reporting details demanded by federal officials.

At the first oversight hearing, held on Oct. 24, there was a lot of jawing back and forth about the responsibility of the contractor, Deloitte, regarding the glitches. Numerous legislators wanted to know why Deloitte had not been fired; administration officials, including Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services, and Michael DiBiase, director of the R.I. Department of Administration, answered that there was a good working relationship between Deloitte and the Raimondo administration, and that the contractor was working very hard, without additional payment, to solve the glitches.

In case you missed it, the legislators had been sparked to take action and hold an oversight hearing after letters from FNS’s Messner were published by WPRI’s Campbell, warning of the potential loss of federal funds. The letters had been received by Rhode Island state officials from DHS before the launch of UHIP on Sept. 13 but apparently never shared; even Gov. Gina Raimondo denied that she had seen them.

Legislators at the Oct. 24 hearing asked for details about the specifics of the rollout: the waiting times, the problems with the phone systems, the glitches with payments being made to those receiving benefits, including SNAP, SSI payments, payments to daycare providers, and termination notices to those receiving health insurance through Medicaid.

Since then, there has been a communications triage team of Brenna McCabe and Ashley O’Shea issuing regular reports to the news media with the latest developments, in the interests of better transparency.

Were internal warnings disregarded?
One line of questioning that the legislators have not yet pursued – and perhaps someone on the joint committee will take up this line of inquiry at the second hearing – is this: were there warnings about the problems with UHIP and Deloitte which were delivered to the top officials in the Raimondo administration that, in turn, were either disregarded or ignored?

And, if so, as a follow-up question: why did those warnings apparently go unheeded?

Two thoughts come to mind around the alleged potential disregard of such warnings: one is how Sean Estin, the loan-portfolio manager at the state’s economic development agency then known as the R.I. Economic Development Corporation, had challenged the lack of scrutiny around the financing deal for 38 Studios in 2010, only to have his concerns apparently ignored by his bosses and never shared with the agency’s board.

If and when the civil lawsuit proceeds in R.I. Superior Court, taxpayers may yet have an opportunity to hear more fully about the concerns voiced by Estin, six years later.

In Estin’s email that has been released as part of court proceedings, it claimed that the 38 Studios deal had received less scrutiny than a $10,000 loan by the agency. It provides a tantalizing bit of evidence that it was known back in 2010, even before the EDC board approved the deal, that financial analysis of the deal was lacking and the numbers may not add up.

Imagine the difference in the future outcomes if Estin’s bosses, including Deputy Director J. Michael Saul and Executive Director Keith Stokes, had heeded Estin’s critical observations?

The second is lyrics from a Pete Seeger song from the 1960s: “We were, neck deep in the Big Muddy, and the big fool said to push on.”