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PHLP eNews

August 2016

PA Health Law News on Hiatus Until September

This month we took a break from reporting on policies, legal decisions, and practices that affect the delivery of health care services and supports for low-income Pennsylvanians.  Our next edition of PA Health Law News will be published in September. 

However, the Pennsylvania Departments of Human Services (DHS) and Aging just announced their selection of three managed care organizations (MCOs) for Community HealthChoices (CHC). CHC will coordinate physical health and long-term services and supports (LTSS) to individuals who are dually eligible for Medicare and Medicaid, older Pennsylvanians, and individuals with disabilities.

Through a review of a request for proposals, the following MCOs have been selected to proceed with negotiations to deliver services statewide in Pennsylvania beginning in 2017:

•             AmeriHealth Caritas
•             Pennsylvania Health and Wellness (Centene)
•             UPMC for You
CHC will roll out in three phases. Persons eligible for CHC are individuals aged 21 or older who have both Medicare and Medicaid, or who receive long-term services and supports through Medicaid because they need help with everyday activities of daily living.

More details about CHC and other programs will be provided in the September edition of PA Health Law News. 

When A Managed Care Plan “Lost” the Paper Work for an Appeal, PHLP Stepped In

Derek is a 24-year-old on the autism spectrum.  He had been receiving occupational therapy--paid for by his Medicaid managed care company--since November 2015, which helps improve his personal hygiene, feeding, and other daily functional tasks.  Suddenly, in June, his occupational therapist’s request to continue services was denied by his managed care company. His mom filed an appeal and contacted the Health Law Project.  We helped the family prepare evidence (e.g., a detailed progress report from Derek’s therapist and a letter from his physician), which was then forwarded to the managed care company.

When there was no response to the appeal from the managed care company, Derek’s mom contacted them only to be told they had no record of the appeal, the therapist's report, or the physician's letter!  Fortunately, Derek’s mom had made a copy of the envelope with the post mark from the postage meter before she mailed it and the occupational therapist’s report had been sent with postal tracking.  PHLP brought this to the attention of state Medicaid officials who oversee the managed care company and they contacted the company.  Within a day, the managed care company not only “found” the appeal and the supporting medical documents, but reversed their decision--authorizing all the occupational therapy visits requested.
Pennsylvania is one of the few states in the country with a non-profit law firm exclusively focused on health care.  The backbone of our work, and the wellspring of our expertise, is helping individuals 1) obtain and keep health insurance OR 2) who have had health services denied, reduced or terminated.  In PHLP’s experience consumers like Derek are more successful when they receive expert guidance about adverse benefit determinations.    

What We're Reading

There's A Simple Fix for Obamacare's Current Woes: The Public Option, Jacob S. Hacker, Vox, August 18, 2016

“When the Affordable Care Act passed in 2010, Sen. Tom Harkin of Iowa memorably called it ‘a starter home.’ Now the home has been built, and it’s in need of some additions. One set of additions relates to getting more people signed up — fighting to ensure that Medicaid expands in all 50 states, creating auto-enrollment features so people who don’t have coverage don’t fall through the cracks, making the subsidies for coverage more generous.

The second set of additions relates to keeping costs down, so the first set of additions is affordable and our nation’s economy and budget are stronger. The public option should be the centerpiece of this second set of improvements to our health care starter home. Think of it as a stronger foundation for a structure that’s already survived stiff partisan winds — and could, in time, make affordable quality health care for everyone a central part of the American promise.”

Administration Paints Rosy Future For Obamacare Marketplaces, Kaiser Health News, August 2016

“Despite dire warnings from Republicans and some large insurers about the stability of the Affordable Care Act exchanges, an Obama administration report released Thursday indicated the individual health insurance market has steadily added healthier and lower-risk consumers.

Medical costs per enrollee in the exchanges in 2015 were unchanged compared with 2014, according to the Centers for Medicare & Medicaid Services. In contrast, per-member health costs rose between 3 percent and 6 percent in the broader U.S. insurance market, which includes 154 million people who get coverage through their employer and the 55 million people on Medicare, the report said.”
Obamacare Appears to Be Making People Healthier, Margot Sanger-Katz, The New York Times, August 9, 2016

“Obamacare has provided health insurance to some 20 million people. But are they any better off? …

A few recent studies suggest that people have become less likely to have medical debt or to postpone care because of cost. They are also more likely to have a regular doctor and to be getting preventive health services like vaccines and cancer screenings. A new study, published Monday in JAMA Internal Medicine, offers another way of looking at the issue. Low-income people in Arkansas and Kentucky, which expanded Medicaid insurance to everyone below a certain income threshold, appear to be healthier than their peers in Texas, which did not expand.

…  Their survey found people in Arkansas and Kentucky were nearly 5 percent more likely than their peers in Texas to say they were in excellent health in 2015. And that difference was bigger than it had been the year before.”

How Parents Harnessed the Power of Social Media to Challenge EpiPen Prices, Tara Parker-Pope, The New York Times, August 25, 2016.

This article—detailing how a group of consumers and citizens lobbied against Mylan’s increased price for the EpiPen—showcases the increasing role social media plays in keeping drug costs down.

“Then Ms. Kantayya shared the link with her 836 Facebook friends, with a post that began, ‘Stupid pharmaceutical company!’

What happened next is a lesson in the power of social media to help create a groundswell, particularly among a group as committed and motivated as the parents of children with food allergies, who must often buy multiple pens for home, school and day care. In just 45 days, Ms. Kantayya’s petition grew from a few dozen signatures to more than 80,000 people who sent more than 121,000 letters to Congress.”

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