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PHLP eNews

May 2016

Health Law PA News

Click here for the May 2016 Health Law PA News.

This month's edition includes the following articles:
  • Community HealthChoices Update: 14 Plans Submit Bids to Participate
  • Medicaid Expansion: One Year Later
  • CMS Reinforces the Prohibition on Balance Billing of Dual Eligibles
  • New Medicaid Managed Care Rules Released by CMS
  • Correction to PHLP D&A Publication

When a Client Faces an Awful Choice, Paying for Medication or Keeping the Electricity On, PHLP Steps In

While the Pennsylvania Utility Law Project (PULP) was helping 64-year-old Columbia County resident Evelyn avoid utility termination, they discovered she was not paying her utility bills because she was paying medical bills. So they referred her to PHLP to see if she qualified for assistance.

Evelyn receives a modest income through Social Security Disability Insurance (SSDI) and a small widow’s pension. She had health care coverage through Original Medicare, leaving her with 20% coinsurance for any health care services she received. Because Evelyn has a number of health problems that require regular care, as well as the use of oxygen, she looked into buying a Medicare supplement policy or a Medicare Advantage plan, but she could not afford them. 

When our staff talked to Evelyn, we discovered she was on Medicaid, but only for the payment of her monthly Medicare Part B premium. We learned she also received the full Extra Help with her Medicare prescription drug costs, but she was still struggling with these costs ($2.95/generic drugs and $7.40/brand name drugs) because of how many medications she has to take for her health conditions.  

Evelyn was only slightly over the income limit for full Medicaid benefits. Although Medicaid, an income based program, does not generally consider household expenses when determining eligibility, there is a little-known rule that allows Medicaid to deduct transportation costs to and from the bank from someone’s income when reviewing eligibility for older adults and people with disabilities. PHLP discovered that Evelyn traveled to the bank a couple times a month to access her Social Security income and, because she lives in a rural area, the number of miles she had to travel to get to her bank would be enough to bring her income below the limit.

PHLP contacted Evelyn’s local County Assistance Office and asked them to review her eligibility taking into account the monthly transportation costs to the bank. They did and approved for her full Medicaid! This covers her Medicare Part A and B deductibles and coinsurance, freeing up some of her limited income to pay other bills, like her utility bills. She also now qualifies for a lower co-pay level with her full Extra Help, reducing her prescription costs to $1.20/generics and $3.60/brand name drugs.

Evelyn is extremely grateful that she can now pay her bills! Her case shows the importance of collaboration between legal services programs-- as well as how important it is to have specialty legal aid programs, like PHLP, whose staff really understands the nuanced rules of Medicaid eligibility to help people like Evelyn get the help they need.

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What We're Reading

Treating Opioid Addiction With A Drug Raises Hope And Controversy, NPR, May 17, 2016

Despite having the backing of the White House (President Obama included $1.1 billion in his 2017 budget to address the opioid epidemic, with almost all of it going toward expanding access to medication-assisted treatment), drugs like methadone and buprenorphine remain controversial. 

Michael Botticelli, director of National Drug Control Policy at the White House, speaks to the problem of those with opioid-use disorders not being offered alternatives when treatment without medications fails them. "We wouldn't do that with any other disease. If one treatment failed for you, we'd say, let's look at other possible treatment options."

Confined to Nursing Homes, but Longing (and Ready) for Home, The New York Times, May 13, 2016

“Across the nation, many other Americans who could live elsewhere with help are unwillingly confined to nursing homes or long-term care facilities. Nearly 20 years after the Supreme Court ruled that disabled people requiring public support were entitled to live in their community, rather than in institutions unless medically necessary, the federal government and states are still far from achieving that goal. Because of budget cuts, inflexible rules, a patchwork of programs and a widespread failure to bolster alternative care, others like Mr. Dawkins describe feeling stuck in deeply unsatisfying, sometimes miserable, settings.”

Get Ready for Higher Obamacare Rates Next Year, The New York Times, May 6, 2016

Many plans on the Marketplace may increase prices by 10 percent or more. However, most people buying insurance on the Marketplace will not feel the effects of these increases because the formula that calculates federal subsidies will offset the increases for them.

How to Improve Mental Health in America: Raise the Minimum Wage, New Republic, May 4, 2016

Britain’s decision to raise the minimum wage in 1998 substantially improved the mental health of low-wage workers by reducing financial strain. Similar results were found in the Oregon Health Insurance Experiment, in which uninsured Portland residents entered a lottery to apply for insurance through Medicaid, reducing their financial strain. 

This piece calls for “preventive mental health care,” public policies that reduce the number of people who become mentally ill. Raising the minimum wage is a way to attack one social determinant of mental health problems, financial strain.

Life Expectancy Study: It's Not Just What You Make, It's Where You Live, NPR, April 11, 2016

A recent study published in the Journal of the American Medical Association (JAMA) found life expectancy disparities based on the wealth of the city in which someone lives. The poor tend to have shorter lifespans than those with more money, but those living in poverty in a more affluent city tend to live longer.
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