PHLP Helps Pregnant 17-Year-Old, Estranged From Her Parents, Obtain Vital Health Services
Last month, PHLP received a call from an advocate at the Maternity Care Coalition (MCC) on behalf of “Maria”, a 17-year-old living in Philadelphia. When Maria’s parents found out that she was pregnant, they kicked her out of their home, so Maria was living with her friend’s family while attending school full-time and trying to prepare for the arrival of her baby.
MCC helped Maria apply for Medicaid/Medical Assistance for herself and her child. However, Maria’s application was denied – twice – because the Department of Public Welfare’s County Assistance Office (DPW) said that she was a minor and needed her parents to apply on her behalf.
With only weeks until Maria’s due date, PHLP worked quickly and found that DPW should have considered Maria an “emancipated child,” because she was not living with her parents or receiving any financial support from them.
PHLP advised Maria and MCC on how to prepare better documentation of her situation, then filed an appeal on Maria’s behalf and contacted DPW to underscore the time-sensitive nature of the case.
Within days, the denial was reversed and Maria was able to access the medical care she needed to keep her and
her baby healthy.
PHLP: Ensuring New Enrollees in Medicaid Managed Care Obtain Needed Care
About half of Pennsylvania’s two million Medicaid recipients are in private managed care plans, and, as reported in our May newsletter
, Pennsylvania is expanding this arrangement, known as HealthChoices, to over 500,000 residents in the remaining 42 rural counties
Pennsylvania officials predict this expansion will save the state money and improve coordination, quality and efficiency of services. But it also comes with significant risks.
PHLP is concerned managed care plans will inappropriately deny care prescribed by a physician. A recent and egregious example PHLP brought to light was denial of home health aide services for a 13-year-old boy, Joseph
, with numerous complex health needs.
Joseph’s parents provide most of his care, but an aide visits his home to assist with activities of daily living—i.e., eating and using the bathroom. PHLP represented the family and successfully helped Joseph’s parents maintain the home support.
Going without needed care causes obvious harm. It also increases cost. Joseph’s experience teaches us that Pennsylvanians with temporary or chronic health conditions or disabilities need help.
PHLP has already published a series of fact sheets about the expansion, advising new enrollees and their advocates on how to choose a managed care plan, and on their appeal rights and options in HealthChoices:
In the months ahead, PHLP will:
ensure new 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;
help these enrollees gather medical records and work with their providers to create compelling letters of medical necessity; and;
represent them in internal grievances, independent external reviews, and fair hearings in matters in which they are at risk of hospitalization or institutionalization.
PHLP Submits Comments on Federally Facilitated Exchanges
In May, the federal department of Health and Human Services (HHS) released guidance
on how it will operate federally-facilitated exchanges (FFE) in states that are not ready to operate their own. It is a sparse 19-pages, but it will have a super-sized impact on how federal health reform is implemented in the months and years ahead.
PHLP submitted comments urging HHS to promulgate regulations that are precise, measurable, and enforceable with the goal of establishing all Exchange operations as consumer-centric.
We strongly support the analysis and recommendations of the Center on Budget and Policy Priorities
, and the Georgetown Center for Children and Families
, and added comments and suggestions specific to Pennsylvania’s context and experience. To view PHLP’s comments click here