Kevin is a 59-year-old man from Erie with multiple significant health issues. When his bathroom fell into such disrepair that he could no longer bathe, he knew it was time to try get his insurance to approve a bathroom modification. He contacted PHLP for help after his Community HealthChoices (CHC) insurance plan denied his request for bathroom modifications, claiming that because his bathroom was in such disrepair, he would need to have it repaired before it could be modified, and such repairs are the homeowner’s responsibility.
Kevin has been in the waiver program for many years and had a previous bathroom modification paid for through the waiver in 2011. Unfortunately, the previous bathroom modification – a walk-in tub – was not installed correctly and had problems from the start, with various leaks leading to the state of the bathroom deteriorating overtime, despite numerous attempts to get the issues fixed. Although it is correct that home repairs are generally the responsibility of the participant, the CHC program defines home modifications to include repair and maintenance.
PHLP worked with Kevin and the company that completed the project proposal for the prior bathroom modification to gather information to demonstrate that the previous bathroom modification was paid for by the waiver program, that it was flawed from the beginning, and that Kevin had attempted to work with the company to fix the issues. We were able to provide proof that the Office of Long-Term Living had approved the prior bathroom modification, which is a prerequisite for getting repairs completed under the waiver. The company Kevin worked with to submit proposals for both bathroom modifications provided a letter indicating that the tub was not installed correctly, resulting in water damage. Kevin testified at his grievance hearing about the 2011 bathroom modification, the problems that surfaced right away, and the efforts made to repair the faulty bathroom modification over the years. He also explained that his health had worsened and that he was only able to sponge-bathe as the walk-in tub had become unusable.
PHLP argued that repairs and maintenance of home modifications are included in the home modification benefit in the CHC program. Given that Kevin’s bathroom was in its current state of disrepair due to a faulty home modification year ago, PHLP argued that the waiver should cover both the needed repairs and the new medically necessary bathroom modification. Thankfully, the CHC health plan agreed with our arguments and overturned the denial. Early in October, the bathroom modification was finally completed, and Kevin is once again able to shower and bathe in his own home safely.