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

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:
  1. 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;
  2. help these enrollees gather medical records and work with their providers to create compelling letters of medical necessity; and;
  3. 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.
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What We're Reading

Emergency Supply of a Prescription that Requires Prior Authorization or a Benefit Limit Exception (Revised), Pennsylvania Medicaid Alert, May 2012
 
Dx For A Careful Approach To Moving Dual-Eligible Beneficiaries Into Managed Care Plans, Health Affairs, June 2012
 
Health Care Reform Memos, a weekly publication of Deloitte Center for Health Solutions
 
Through the Lens of Equality: Eliminating Sex Bias to Improve the Health of Pennsylvania’s Women, Women’s Law Project, April 2012
 
Uninsured Veterans and Family Members: Who Are They and Where Do They Live?, Robert Wood Johnson Foundation, May 2012
 
Florida v. Department of Health and Human Services: Possible Outcomes for Pennsylvania after the U.S. Supreme Court’s Ruling on the Affordable Care Act, Community Legal Services, June 2012

Spotlight on Advocacy

By the end of June, the Supreme Court will issue a landmark ruling on the constitutionality of the Affordable Care Act.

In the upcoming weeks, our website will feature updates on the Court's decision and the impact it will have on our most vulnerable citizens.

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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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