Tuesday, December 10, 2013
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Gail Kennett, now in the late stages of Lou Gehrig’s disease, has been a critical-care patient at Maine Medical Center since February 2012.
John, 72, who retired in 2003 after 39 years as a high school history teacher first in Madison and then in South Portland, assumed his retirement health plan with Anthem through the Maine Education Association Benefits Trust would cover Gail for what was left of her life.
But less than a month after Gail's admission to Maine Medical Center, Anthem notified her that it would stop covering her care effective March 16, 2012.
And so the battle began.
"They (Anthem) say she appears ready for a lower level of care, but don't say when or where," wrote John in a plea for help to the Maine Education Association Benefits Trust, which contracts with Anthem to provide health coverage for its retirees.
"Maine offers no such facilities for patients on ventilators and there is no place for her to go," he continued. "There was no expression of sympathy or offer to provide help on the part of Anthem. As a Maine company servicing Maine people, I would have expected more."
His plea fell on deaf ears. After reviewing the Kennetts' request that they intervene with Anthem, the MEA Benefits Trust board of trustees informed John last month that they "reluctantly voted to decline further intervention" on the grounds that Anthem has complied with the terms of its plan and the doctor from Pennsylvania (however problematically) ruled against continuing Gail's coverage.
All of which leaves the Kennetts, at perhaps the most vulnerable point in their lives, mired in definitions, disclaimers and denials that all add up to one message: We're done. You're on your own now.
Anthem, backed up by Lamprakos' legally required outside review, says Gail fits the company's definition of "custodial care," meaning it "does not meet the criteria for skilled nursing or skilled rehabilitation services." And since Anthem doesn't cover custodial care, the company says, it's under no obligation to pay.
On the Kennetts' side are Dr. Mette, who as far back as last September cited Maine Medical Center as Gail's "only option," and Paula Banks, a social worker and consultant whose resume includes discharge planner and care coordinator at Maine Medical Center and admissions director and clinical services director at Cedars Healthcare Center in Portland.
"How any doctor, nurse, clinician, hospital administrator, Anthem UM reviewer or layman could think that Gail is at any 'level of care' other than acute is beyond my comprehension," wrote Banks last month in a letter to John Doyle, the Kennetts' attorney.
For starters, noted Banks, the myriad daily tasks needed to keep Gail alive at the hospital -- hooking her up to an "in-exsufflator" four or five times a day to make her cough, for example, or frequent "deep suctioning" to keep her lungs from filling with fluid -- can only be performed by a registered respiratory therapist.
But the bigger problem is that outside of the hospital and two out-of-state facilities (one in Laconia, N.H., the other on Cape Cod) that lie far beyond John's ability to faithfully sit by his wife's side day in and day out, there's simply no place else for Gail to go.
Attached to Banks' letter is a list of 38 skilled nursing facilities she contacted to see if they could handle Gail's care. The vast majority of the recorded responses simply say "cannot meet patient's needs." A few others paint an even bleaker picture.
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