Pennsylvania Health Law Project: Helping People in Need Get the Health Care They Deserve

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.
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PHLP in The News

Cost Preventing Many Pennsylvanians From Getting Medical Care They Need, Study Shows, Allentown Morning Call, 5/8/12

What We're Reading

Fact Sheet: Five Key Questions About Medicaid And Its Role in State/Federal Budgets and Health Reform, Kaiser Family Foundation, May 2012

Advocates Worry States are Moving Too Fast on Dual Eligibles, Kaiser Health News, May 2012

Implementing Health Reform: Increasing Medicaid Payments for Primary Care Physicians, Health Affairs Blog, May 2012

Study: States should limit number of plans in exchanges, Healthwatch Blog, May 2012

Spotlight on Advocacy

On May 31st, PHLP will conduct two trainings on the HealthChoices Southwest Expansion to Bedford, Blair, Cambria, and Somerset Counties. For more information, click here
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The Pennsylvania Health Law Project is a nationally recognized expert and consultant on access to health care for low-income consumers, the elderly, and persons with disabilities. PHLP engages in direct advocacy on behalf of individual consumers while working on the kinds of health policy changes that promise the most to the Pennsylvanians in greatest need.
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