Complaint·March 7, 2024

Complainant alleges that the Provider made material misrepresentation about accepted healthcare and changes were made to the Continuing Care Contracts that were not previously approved by residents or the Continuing Care Contracts Bureau. The Department interviewed complainant and Kim Dominy, Executive Director and reviewed the Continuing Care Contract, Quick Guide: Insurance for Health Center Stays and documentation that was provided to Casa residents regarding Medicare vs Medicare Advantage HMOs. The continuing care contract required residents to “enroll at your own expense in Medicare (Parts A and B)”. Furthermore, the contract states “If you choose HMO coverage rather than Medicare, Casa reserves the right to charge you market rates for any services you receive”. On September 22, 2023, Provider provided a Quick Guide which included a list of approved insurers and insurance companies that will no longer be contracted with Casa effective January 1, 2024. The document clarifying coverage does not constitute a change of the contract. Sections IV(F) and (J) of the Casa Contract provide that Casa de las Campanas is able to be paid for its services by Medicare or from a third party on similar terms and at the same rate, requiring residents to obtain Medicare Parts A and B or the equivalent. Thus the Casa Contract properly reserved for the provider the right to reject Medicare Advantage HMO type polices. Based on the review and investigation the Department finds the allegation “unsubstantiated”. Complaint finding were delivered telephonically and LIC 9099 was signed and emailed.