A private company that the state has tasked with providing Medicaid coverage to Texas foster children has repeatedly denied requests for critical care, many for children with disabilities.
Between June 7 and July 13, Superior HealthPlan denied medical services to foster children 394 times, according to data the Texas Department of Family and Protective Services provided to the American-Statesman. The agency, which oversees the state’s child welfare programs, started tracking the denials of service last month, in an effort to determine how the denials are affecting foster kids. Foster parents have reported denials from managed care organizations for years.
Company officials dispute the state’s figures and say Superior approves necessary medical care; foster care parents and advocates say the requests for service were for medically necessary treatment.
The issue is receiving renewed scrutiny from lawmakers and state officials.
“Many of the children in our care have suffered extreme abuse and neglect and have complex medical conditions. Any one of us would give anything to help our children, which is why we fight to meet their needs, no matter what hurdles stand in our way,” Hank Whitman, commissioner of the Department of Family and Protective Services, said in a statement to the American-Statesman.
“These children are more than a (managed care) contract, and we will continue to strongly advocate for any medical care or treatment that we feel is necessary,” Whitman said.
Under direction from the Legislature, the Texas Health and Human Services Commission has overseen the transition of most Medicaid services to private companies called managed care organizations over the past two decades; the health agency continues to oversee the managed care organizations. The move to managed care is supposed to improve health care while saving the state money — an estimated $3.8 billion over a six-year period, according to a study by the Texas Association of Health Plans in 2015.
However, critics of managed care as well as parents inside and outside of the foster care system have said children with disabilities have suffered from the decisions of managed care organizations.
Foster care children, who are all entitled to Medicaid coverage, were folded into managed care in 2008. Superior was awarded the sole contract, currently enrolling 34,000 foster children. The company was paid $365 million in fiscal year 2017.
Officials with Superior said they carefully review every request for service and that the number of denials the state has reported doesn’t match the company’s data. Superior, however, did not provide any figures.
“What we can say without hesitation is that Superior is committed to serving our members and providing the best and highest quality of care as medically necessary,” said Michael Cation, a spokesman for the managed care organization. “Superior has a long-standing practice of working alongside providers, as well as caregivers and state agencies, to ensure we provide the best care and support that children and youth in foster care need.”
Officials with the Health and Human Services Commission, which oversees the contract with Superior, said the vast majority of foster care requests for service are approved but could not provide figures. The agency’s contract with Superior also requires company employees to discuss with the child’s provider the needs of the child and allow the provider to present other information on medical necessity before issuing a denial.
A spokeswoman said the agency hasn’t yet determined if the rate of denials is excessive.
“We want to put the data in context and know whether DFPS (or medical consenter) plans to appeal any of the denials. That’s a critical piece of the picture,” said Carrie Williams, spokeswoman for the Health and Human Services Commission.
Decisions to appeal are typically left up to foster parents, but the Department of Family and Protective Services is gathering information to determine whether to intervene.
Texas House members grilled Superior officials last month after a Dallas Morning News investigation detailed a Dallas foster boy’s struggle to get nursing care. The boy was denied a 24-hour nurse to help ensure he wasn’t pulling out his breathing tube. He later became brain dead after he dislodged the tube during the hours before his nurse arrived.
A Texas Senate committee is expected to hold a hearing on foster care health services in September.
“There continues to be scrutiny on the delivery of services to our most vulnerable Texans as we approach the next legislative session,” Sen. Jane Nelson, R-Flower Mound, chairwoman of the Senate Finance Committee, said in a statement. “We are working on several fronts to ensure that clients receive the services they need and that contractors are held accountable.”
‘Feels like they’re giving up’
Luz, 4, was born with a genetic disease and cerebral palsy and is unable to breathe or eat unassisted. Doctors say she’s not expected to live past her fifth birthday. For most of her life, Luz, whose last name is kept confidential to protect her privacy per state policy, has been in foster care.
Luz’s foster mom, Robin Batts, who lives in Harker Heights, hasn’t received approval for more equipment that removes mucous from Luz’s airway. Parts of the equipment should be changed daily but instead are changed every two days, putting Luz at risk of an infection, Batts said.
“They said it’s not medically necessary for us to change that. Yes, it is (necessary). Absolutely,” Batts said.
Batts with support from her providers had asked Superior to approve Luz for physical therapy, which helps keep her limber, for six months at a time. Recently, Superior decided to approve physical therapy for eight-week periods, forcing Batts to reapply for the therapy more often. Superior has stopped occupational therapy altogether.
“They felt like she wasn’t making enough progress, which hurts my soul. You should just keep trying. … It feels like they’re giving up,” said Tesleigh Eure, who has been Luz’s foster caseworker since she was a baby.
Lozana Prescott, who lives in Lindale in East Texas, has seen Superior cut or threaten to cut services for each of her five foster children, all of whom have disabilities.
Prescott is asking for a hearing to appeal Superior’s decision to cut 7-year-old Nathan’s personal attendant services to 20 hours a week from 28 hours a week. Nathan was born with contracted joints and uses a wheelchair. At one point, he received 38 hours of personal attendant services a week.
Prescott said she relies on the attendant to help teach Nathan how to become independent. Superior recommended a machine that can lift him in and out of his bed and chairs, but the attendant does much more than moving Nathan around, including administering physical therapy, Prescott said.
“My children are not going to be robbed if I can stop it,” said Prescott, who has gone through four other hearings to fight for services. “They’re breaking our back. They’re making it impossible for me to keep these children safe.”
Bureaucratic denials, few providers
Of the 394 foster care denials the Department of Family and Protective Services has tallied, Superior rejected 300 requests for service because the company determined they weren’t medically necessary. Superior determined the rest were for services that weren’t covered by Medicaid.
Among the services and equipment denied were cranial helmets, therapies, drug rehabilitation and psychiatric hospitalization, according to redacted copies of denials provided to the American-Statesman.
“There’s a lot of denials based on some provider not filling in the right form or getting the right paperwork to the right person on the right day. It’s bureaucratic denials. I don’t argue with them anymore. I go to the courts that handle the (Child Protective Services) cases,” said Matthew Trail, Houston-based supervising attorney for the advocacy group Disability Rights Texas’ foster care team.
Occupational therapy for one of Liz Sargent’s twin 4-year-old foster boys was cut earlier this year and won’t resume until August at the earliest because the child’s doctor failed to provide paperwork that she didn’t know Superior required.
Sargent’s biggest challenge, however, is finding a psychiatrist who will see one of the boys. He has a slew of psychiatric diagnoses stemming from possible physical and sexual abuse he suffered before he entered foster care.
Sargent said many of the Houston-area psychiatrists on Superior’s list do not accept Medicaid anymore or have long wait times for appointments. The next available appointment she could find with a psychiatrist in Houston is in January, she said.
“It’s that extra layer of work that actually prevents more foster families from accepting more children,” Sargent said. “I’m licensed for four, but I can’t take in two more children if I have to fight for every single service or I have to go through three of four days of calling doctors that supposedly take an insurance but are no longer taking it.”
Sen. Charles Schwertner, R-Georgetown, wrote a bill in 2015 requiring managed care organizations to publish online a list of providers accepting Medicaid. He said the Legislature should continue to scrutinize the managed care system.
“No child should have to suffer while bureaucrats argue over whether or not to approve the care and support they need,” Schwertner said in a statement.
Amid complaints about managed care, the Health and Human Services Commission is adding 47 more people to a team that visits with Medicaid patients to determine if they’re receiving necessary care. The agency also tracks whether denials are happening systemically in certain Medicaid programs over others.
State District Judge Darlene Bryne, who oversees all child welfare cases in Travis County, said the state government is directly responsible for denying Medicaid services to foster children.
“The parent is the state of Texas,” Bryne said. “The state needs to pony up to the bar regardless of which fragmented piece of the state or private company they contracted with that they punted their parental obligations down to. The buck stops with the state.”