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Maria Cepeda said she knows exactly how she will end her life. She won’t use pills as she has several times before. Her final attempt, she said, will be with a rope, and alcohol will buy her the courage.

“My last way, my final out, will be a hanging,” said Cepeda, who suffers from severe depression, bipolar disorder and post-traumatic stress. “And like I told my brother, there will be no more suicide attempts. There will be one more and I will succeed.”

For now, the 42-year-old Sebastopol resident, who lost both her best friend and her mother this year, said she’s holding on, keeping her “mental demons” at bay. When her world starts to go “black,” Cepeda said she still has the rationale to check herself into a local emergency room, with the hope of being admitted into an inpatient psychiatric facility.

For Cepeda and hundreds of other Sonoma County residents, that usually means waiting hours while hospital staff searches for a bed in a facility outside the county.

Because Cepeda’s health care is covered by Medi-Cal, the state’s Medicaid program for low-income residents, she essentially is ineligible to stay at Aurora Santa Rosa Hospital, the new for-profit private inpatient psychiatric hospital in west Santa Rosa. The Fulton Road facility, which opened last year, is located at the site of the psychiatric unit previously operated by Santa Rosa Memorial Hospital before being shut down in 2008.

A little-known federal rule that goes back to the creation of the Medicaid program in the mid-1960s tightly restricts the use of federal Medicaid matching funds to pay for care at “institutes of mental disease,” or IMDs, residential treatment facilities with more than 16 beds whose primary purpose is to serve those with mental illness.

Known as the IMD exclusion, the rule was established at a time when state-run mental institutions were receiving serious scrutiny and criticism for “warehousing” mental health patients. The rule reflected the federal government’s wish to stop funding such institutions.

Since then, the number of state-run mental health facilities has declined dramatically.

The IMD exclusion does not apply to inpatient psychiatric facilities that are tied to general acute care hospitals, such as the one operated by Marin General Hospital in Greenbrae. And it does not apply to people younger than 22 or older than 64.

However, the number of these hospital-affiliated units also has declined as hospitals close inpatient psychiatric facilities to reduce costs. Memorial Hospital shuttered its psychiatric unit — the county’s only remaining inpatient psychiatric hospital — in 2008 as part of a large cost-cutting plan.

Wide age range ineligible

At hospital-affiliated psychiatric units, Medi-Cal pays for about half the cost of a patient’s stay, and counties pay the other half.

But under the IMD rule, Medi-Cal will not pay for any care provided to patients ages 22 to 64 at freestanding psychiatric hospitals, like Aurora Santa Rosa Hospital, that are not tied to a general acute care hospital. As a result, these patients usually are sent out of Sonoma County to other facilities.

Seventy percent of the Sonoma County residents who were hospitalized last year for mental health treatment fall within this age group, said Michael Kennedy, the county’s mental health director.

“To not provide a psychiatric hospital benefit for this age group is discrimination,” Kennedy said.

During the 2013-14 fiscal year, the county’s mental health department hospitalized 894 local residents, Kennedy said. Some were covered by Medi-Cal, others had private insurance, and some had no insurance at all. The average daily cost at a psychiatric unit is about $1,000 to $1,200 per patient, Kennedy said. The county does not have the financial resources to send Medi-Cal patients to Aurora Santa Rosa Hospital unless the state insurance program picks up half of the cost.

Kennedy said that modern freestanding psychiatric units are nothing like the old state-run mental institutions the federal government began defunding decades ago.

“We are saying that they need to clarify that freestanding psychiatric hospitals are not IMDs,” he said.

Long waits, distances

Since 2005, Cepeda has checked herself into psychiatric units a half-dozen times, she said. She was able to stay at the Fulton Road facility when it was operated by Memorial. But since then, she’s had to go to facilities outside Sonoma County, to cities like Greenbrae, Fairfield, Sacramento and even as far as Modesto.

Cepeda said her “decompensation” process is familiar, and it starts with a gradual darkening of the world around her.

“It’s hard, it feels black. It feels —” She paused, struggling for the right words. “It feels like nothing more can be done here and it’s over. If it’s completely colorless, it’s over.”

That’s when Cepeda is overcome with suicidal thoughts. While the emergency room becomes her refuge from those thoughts, she and other county Medi-Cal patients often have to wait many hours before psychiatric staff can find an opening at the nearest psychiatric unit. Sometimes the wait can be as long as 48 hours, she said.

Of the county’s 894 psychiatric hospital admissions in the 2013-14 fiscal year, 80 percent were sent to three hospitals: Aurora Santa Rosa, 29 percent; Marin General, 26 percent; and St. Helena Hospital sites in Vallejo and Napa, 25 percent.

The remaining 20 percent were admitted to one of 26 other hospitals, most of which are in the greater Bay Area, including Oakland, San Francisco, Berkeley and Burlingame. Sometimes, hospitals in the Sacramento area are used if closer units are full.

While some Sonoma County residents also receive services in hospitals as far north as Redding or as far south as Costa Mesa in Southern California, these cases usually involve locals having crises in those areas, making placement in the nearby hospital the best option, Kennedy said.

The county also contracts with Progress Foundation for a 10-bed crisis residential unit in Sonoma County, Kennedy said. Progress Foundation, a private, nonprofit mental health agency that also operates units in San Francisco and Napa counties, is an alternative to inpatient hospitalization.

Kennedy said research shows such programs are a more effective approach to crisis care than inpatient psychiatric units. The crisis residential unit, which takes patients with no insurance and those with Medi-Cal, runs at more than 90 percent occupancy and helps mitigate the need to send clients outside the county.

“We are currently working on opening another 10-bed crisis residential program,” he said, adding that such services are “Medi-Cal billable.”

Out-of-county stays often are a burden to both the patient and his or her family. Finding an out-of-county psychiatric bed takes time, and patients often endure long stays in emergency departments. Family visits to distant psychiatric units are more difficult, and the patients often experience the stress of being in an unfamiliar community.

‘A very common story’

The IMD exclusion ensures that adult, low-income patients usually will be sent out of the county. It prevents local health officials from providing “life-saving” health care that residents need, said Paul M. Samuels, director and president of Legal Action Center, a national nonprofit law and policy group that focuses on addiction and criminal justice issues.

“It’s a very common story that we’re hearing across the country,” said Samuels, speaking by phone from New York. There is great need for “residential addiction and mental health care, but Medicaid will not pay for it,” he said.

Samuels said his group has been trying to bring attention to the outdated federal rule for many years. Now, with the expansion of Medicaid under President Barack Obama’s Affordable Care Act, the need to modify the rule has become more imperative, he said.

States that are expanding Medicaid under the Affordable Care Act may decide that Medicaid should be the sole payer for health care services, he said. Since Medicaid won’t pay for residential treatment, “that would lead to a perverse irony,” a decrease in the availability of these services, he said.

“We’re worried that states would rely on Medicaid and withdraw the funds that they had been appropriating,” he said.

There is some movement to try to get the IMD exclusion modified, Samuels said.

This year, U.S. Rep. Marcia Fudge, D-Ohio, introduced legislation that would allow a limited use of Medicaid funds for substance abuse treatment provided in community-based IMDs. The legislation authorizes a five-year demonstration project to be conducted in eight to 10 states.

If successful, the project could bring more attention to the need to modify the federal rule.

Kennedy said there are about 2,000 beds in freestanding psychiatric units across the state. Another 2,000 psychiatric beds are found in facilities tied to general acute care hospitals.

“It would double the availability of Medi-Cal beds for adults,” he said.

Kennedy said that modifying the IMD exclusion could result in the share of county patients going to Aurora increasing from 29 percent to 50 or 60 percent.

Rule called discrimination

Ken Meibert, Aurora’s CEO, agreed that the federal government’s exclusion of Medi-Cal patients amounts to discrimination. “Just because they have a different type of insurance should not preclude them from the type of care everybody else gets,” Meibert said.

“The whole marketplace has changed,” he said. “With the advent of treatment and interventions, state hospitals are minimally used. It’s just an antiquated law.”

Aurora is currently ramping up to its 95-bed capacity, Meibert said. With four units open and six psychiatrists on staff, the hospital currently treats adults and adolescents with 76 available beds.

“As we gain more staff, we’re able to open more units,” Meibert said.

Cepeda said she remembers how convenient it was to be treated at the Fulton Road psychiatric unit.

“It doesn’t have beds for people who are on Medi-Cal,” she said. “A lot of people who really need help can’t get a bed there.”

You can reach Staff Writer Martin Espinoza at 521-5213 or martin.espinoza@pressdemo crat.com. On Twitter @renofish.