Parents protest Medica’s new benefit limit for children with severe disabilities

Medica’s new coverage limit on at-home nursing services could create new hardships for families with severely disabled children who need around-the-clock monitoring.

Brandon and Emily Walter joined with home health and disability advocates on Wednesday to protest Medica’s policy change, which will take effect in January.

Even if the state Medical Assistance program picks up coverage when their private Medica policy reaches its new limit, the Medina couple said it will cost them money and force them into tough choices about the therapies and support services they can afford for their four-year-old son, Chase.

Chase has severe disabilities and qualifies for 12 hours per day of at-home nursing, in part to monitor the tracheotomy tube in his throat and a gastric tube in his stomach that provides nutrition, his mother said.

“If his trach tube comes out, he can’t breathe,” she said.

Medica in a written statement said it received assurances from state regulators that its benefit limit is legal and that Medical Assistance will pick up coverage of at-home nursing when that limit is reached.

The switch affects about 20 families with Medica plans, the insurer said.

Pediatric Home Services (PHS), the agency that provides Chase’s nursing care, organized Wednesday’s event at the State Capitol to increase public pressure on Medica. The agency questioned Medica’s interpretation of state law, which was enacted in 2010 and states that at-home nursing “shall be covered” by private insurers for patients who also qualify for public Medical Assistance due to their disabilities.

“This isn’t about special treatment,” said Adam Nielsen, PHS’ chief executive. “It’s about access to medically necessary care. It’s about honoring long-standing policy commitments to Minnesota’s most vulnerable children.”

State Rep. Erin Koegel, DFL-Fridley, joined in opposing Medica’s policy limit, arguing that it will essentially shift costs of life-sustaining medical care for children from the insurance company to taxpayers.

Advocates urged Medica to at least delay the switch to give the Legislature time to address or fix any confusion over state law.

The dispute pits providers and families against a health plan that they acknowledge has been more generous than others. Medica’s plan had a written limit of about 10 days of 24-hour at-home nursing, a spokesperson said, but it had been routinely going beyond that and providing 12- to 24-hour nursing coverage for the entire year for these children.

“If others find out Medica is doing this, and is allowed to get away with it, they will try to follow suit,” Brandon Walter said.

Advocates estimated there are about 2,000 medically fragile children receiving at-home nursing services.

The Walters said it will not be a simple transition from Medica to Medical Assistance program funding when they reach the coverage limit. First, they said they will have to exhaust a special pool of funding set aside under a state waiver to provide for Chase’s other medical needs and support services.

The family had used some of that funding to pay retention and performance bonuses to keep the same nurses coming back and caring for their son. The constant turnover didn’t matter as much when Chase was an infant, but the parents said it matters now that he is more aware and goes by bus to preschool with his nurse.

“A new person coming in, it would take weeks or months to gain a level of trust that is needed,” his father said.

“His room is all space,” his father said. “Our living room is pretty much all space.”

The parents worry about how disrupted benefits could disrupt his progress. Emily Walter said the Medica plan helped the family gain support services to get Chase home from the hospital after his birth in weeks rather than months. If families need to keep such disabled children in hospitals for weeks or months more, that will end up being more expensive for everyone.