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PHLP eNews

October 2015

Health Law PA News

Click here for the September 2016 Health Law PA News.
  • Community Health Choices Updates 
  • Medicare Open Enrollment Starts October 15th 
  • Part D 2017 Costs Announced 
  • Marketplace to Medicare Letters being sent 
  • Six Pennsylvania Organizations Continue Receiving Navigator Grants 
  • Thousands of Providers Dis-enrolled from Medicaid 
  • Actions Taken to Improve Access to Pediatric Shift Nursing and Home Health Aide Services for Children on Medicaid 
  • Re-Designed CHIP website 
  • Pittsburgh Office Move

Helping Seniors Navigate the Aging Waiver Process

Navigating Medical Assistance can be confusing for aging Pennsylvanians.  Viola, a 64-year-old Philadelphia woman, is representative of older adults we help; adults who want to stay in their homes as long as they can; adults profiled recently in the Philadelphia Inquirer article, “Aging in Place” (see “What We’re Reading”).  Viola applied for an Aging Waiver, which allows older adults to receive skilled care and personal care assistance in their homes instead of going into a nursing home. Over the course of three months, she was unable to get a clear answer on the status of her application, and many of her messages were left unanswered.  Frustrated from receiving the run-around, Viola reached out to PHLP.

PHLP worked tirelessly in search of Viola’s missing paperwork.  Working with the Philadelphia Corporation for Aging (PCA), Maximus, and the Office for Long Term Living to locate the application, PHLP was able to secure a follow-up appointment for Viola.  She was quickly approved for the Waiver, allowing her to take full advantage of her benefits and her independence.

To help clients like Viola, please consider making a donation to PHLP today.

Donate to PHLP

PHLP Advocacy Improves Access to Pediatric Shift Nursing and Home Health Aide

This month, Pennsylvania Medicaid officials took an important step toward improving medically vulnerable children’s access to home care, specifically Shift Nursing and Home Health Aides (HHA).  As reported in the September edition of PHLP’s PA Health Law News, the state clarified how Medicaid managed care (HealthChoices) plans should determine “medical necessity” for these services.  “Medical necessity” is the legal and clinical standard for such care.  PHLP sought these changes on behalf of our pediatric clients who frequently encounter problematic denials and face procedural challenges when appealing their health plan’s denials of shift nursing and home health aide services.  Now, when a managed care plan denies a request for pediatric home care, the plan must include a written explanation of the specific reasons why the service was determined not to be medically necessary.  Moreover, a request for in-home nursing may not be denied for any of the following reasons: 
  • Because a parent or caregiver is present in the home, unless the plan has adequate documentation that substantiates the parent or caregiver is actually able and available to provide the child’s care during the time hours are requested;
  • Because the service will be provided in a location outside of the child’s home (e.g. school);
  • Because the plan believes that the service should be covered as part of a child’s Individualized Education Program (IEP) or Section 504 Plan. 
 PHLP continues to advocate on behalf of families to help improve their children’s access to quality Shift Nursing and HHA services at home and in the community.

What We're Reading

Study Finds Seniors Benefit When Asked How To Help Them, Rachel Bluth, Kaiser Health News, September 7, 2016

A study conducted by the Center for Medicare & Medicaid Innovation evaluated the importance of working with low-income seniors to tailor their care plans and improve their physical surroundings.

“The long-term effects of CAPABLE are still being studied by the National Institutes of Health and the Center for Medicare and Medicaid Innovation.

Though the cost savings are unknown, Szanton said it isn’t hard to see how CAPABLE could save money in the long run. The program cost around $3,000 per participant, but according to federal data, a semi-private room in a nursing home costs an average of $6,235 per month.

A version of CAPABLE is being studied in Michigan as a potential cost-saving program, and Szanton envisions it being incorporated into Medicare Advantage plans, accountable care organizations and Medicaid Waiver programs aimed at keeping people out of nursing homes.”
National, Pittsburgh Efforts Dovetail in Focus on Caregivers, Gary Rotstein, Pittsburgh Post-Gazette, September 13, 2016

Pitt professor Richard Schulz headed the National Academies of Sciences, Engineering and Medicine panel that produced a study on caregiving in America, and will also lead The Caregiver Project in Pittsburgh.

“It would represent progress simply to identify those among an estimated 17.7 million family caregivers who are most in need of relief from physical, mental or economic hardship, but Mr. Schulz is hoping both national and local efforts will also provide means of helping them. He is most concerned about the 8.5 million or so caregivers responsible for individuals with dementia or physical disabilities rendering them dependent on others for basic daily care.”
Study: Elderly’s Family Caregivers Need Help Too, Rachel Bluth, Kaiser Health News, September 13, 2016.

 “According to the report, people who help elderly family members with three or more personal tasks a day devote 253 hours a month to caregiving — almost the equivalent of two full-time jobs…

…Lost wages and benefits average $303,880 over the lifetimes of people 50 and older who stop working to care for a parent, according to a study cited in the report. That’s not all: A lower earnings history also means reduced Social Security payments for caregivers when they become eligible.”
Lack Of Medicaid Expansion Hurts Rural Hospitals More Than Urban Facilities, Shefali Luthra, Kaiser Health News, September 7, 2016

This article examines the ways in which Medicaid expansion can increase resources and improve care at rural hospitals.

“Specifically, the researchers, from the University of North Carolina Chapel Hill, found that rural hospitals saw an improved chance of turning a profit if they were in a state that expanded Medicaid — while in city-based hospitals, there was no improvement to overall profitability. Across the board, hospitals earned more if they were in a state where more people had coverage and saw declines in the level of uncompensated care they gave.

To put it another way: All hospitals generally fared better under the larger Medicaid program, but there’s more at stake for rural hospitals when the state expands coverage.”

How Yelp Reviews Can Help Improve Patient Care, Aaron E Carroll, The New York Times, September 12, 2016

This article posits that Yelp reviews of hospitals provide a much more holistic picture of wellness than hospital-based surveys.

“Researchers compared the content of Yelp narrative reviews with the factors considered important in the hospital consumer assessment survey. They found that Yelp reviews did cover most things the survey tallied. But they also covered an additional 12 criteria not in the survey.

These included the cost of a visit; insurance and billing; scheduling; compassion of staff; family member care; and the quality of many staff members. All of these things were important to patients, and all might be correlated with outcomes. More important, nine of the 15 most prevalent criteria in reviews were not included in the survey.”
Leaving Philly jail with mental illness, five days' medication - and now, a fighting chance, Samantha Melamed,, September 5, 2016

New initiatives will make it easier for people to hold onto and sign up for Medicaid after being released from prison. This will both save taxpayer money and shorten the gap that a newly-released person spends without access to medication.

“Right now, three-quarters of all men and women arriving at Philadelphia jails are on drugs. About 28 percent have hypertension, diabetes, or significant seizure disorder. About a thousand each year will be treated for HIV. Fourteen percent have serious mental illness, and 40 percent will require psychotropic medication; Herdman notes the prison system is effectively the state's largest psychiatric hospital.

But only about 8 percent, at last count, had health insurance - all of it Medicaid. Right now, that benefit is terminated in Pennsylvania when people are imprisoned; but, starting in November, it will instead be suspended for up to two years.”
It’s Easy for Obamacare Critics to Overlook the Merits of Medicaid Expansion, Aaron E. Carroll, The New York Times, September 26, 2016

Multiple studies show that Medicaid has had long-reaching, positive effects throughout the last 4 decades.

“It is true that providing Medicaid can cost the federal government, and even states, a lot of money, which can’t then be spent on other worthy pursuits. It is true that Medicaid reimburses physicians and hospitals less generously, and that it often leaves beneficiaries with fewer choices than private insurance might.

But when we look at the balance sheet for Medicaid — health benefits, financial security, societal improvements through education — it’s not hard to argue that money allocated to Medicaid is well spent.”
Aging in Place, Stacey Burling, Philadelphia Inquirer, October 2, 2016

“Staying in a family home can become a strain for both the elderly and their adult children… Overwhelmingly, older adults at all socio-economic levels say they want to stay in their homes as long as they can.  … It's a difficult subject to study, and science has little to offer about whether frail elders are generally happier, mentally sharper, or healthier in their longtime homes or apartments, their children's homes or assisted living facilities. Families have to feel their way through, sometimes with the help of counselors, care managers, doctors, and lawyers. If parents will accept help - and many balk - modern technology and in-home services can help seniors stay at home, but not always to the end.”

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