PHLP Helps 13-Year-Old Maintain Crucial Behavioral Health Services
Thirteen-year-old “Matthew,” from Cumberland County, was temporarily living in a residential treatment facility to deal with significant mental health issues when his mother called PHLP. Matthew’s Medicaid behavioral health insurer was refusing to continue that course of treatment, she explained, citing the cost of residential care.
The treatment team—including Matthew, his psychiatrist, and Matthew’s mother—sought to continue temporary residential treatment because Matthew’s behaviors, including sexual aggression, could not be managed at a lesser level of care. The insurer, however, denied the recommendation. The family unsuccessfully appealed twice before turning to PHLP for help. Without residential treatment, the family worried Matthew would become entangled in the juvenile or criminal justice systems.
Though Matthew’s mother was a determined and persistent advocate, she needed PHLP's expertise to make her case. PHLP obtained and reviewed copies of Matthew’s recent medical records, including numerous psychiatric and psychological evaluations, and advised the family about their relevance for an appeal to an external reviewer. The hard work proved successful: the external reviewer overturned the insurer’s denial after finding residential treatment was necessary to meet Matthew’s medical needs.
Matthew’s family was relieved and grateful that PHLP was there to help.
Ensuring Health Access as Pennsylvania Dramatically Expands Medicaid Managed Care in Rural Areas
Pennsylvania is making fundamental and far-reaching changes to its Medicaid program by expanding mandatory managed care for Medicaid beneficiaries. As noted in the January edition of our Health Law PA Newsletter
, the Department of Public Welfare (DPW) decided to expand HealthChoices statewide over the next year.
This change will impact approximately 465,000 residents in 42 of the Commonwealth’s most rural counties; counties whose populations rely heavily on Medicaid, but have little familiarity with managed care. Instead of directly paying a health care provider, the Commonwealth will pay an insurance company to manage the delivery of physical health care.
DPW’s changes are motivated by efforts to control growth in Medicaid costs, but they place Medicaid beneficiaries (primarily children and persons with disabilities) at risk. Research and PHLP’s experience shows that health services prescribed by a doctor do not come easily even to the most vulnerable. Many Medicaid beneficiaries do not realize they have a right to challenge insurers’ decisions denying them care or the process discourages them.
In the months ahead, PHLP will help Pennsylvanians unfamiliar with managed care (as well as their family members, and professionals who serve them) understand how to get their needs met. Through webinars and trainings, PHLP will ensure new Medicaid managed care enrollees denied care know how to file a grievance and request a fair hearing, know the relevant timelines for filing an appeal, and know what to expect in each stage of the proceeding; and PHLP will represent them in internal grievances, independent external reviews, and fair hearings when they are at risk of hospitalization or institutionalization.