Read our Health Law PA News, find out about upcoming trainings, and more in this month's edition
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PHLP eNews

November 2015

Health Law PA News

Click here for the November 2015 Health Law PA News.

Increasing Independence for Nate

Due to spina bifida and developmental delays, four-year-old Nate is unable to walk, stand or crawl independently. He has always relied on a caregiver to carry him from place to place or push him in a toddler stroller to get where he needs to go.  This summer, Nate’s team of doctors and therapists recommended a power wheelchair, which would increase Nate’s independence and allow him to explore and interact with his environment at home, school, and in his community. Nate tested a power wheelchair and immediately his parents noticed a positive improvement as they watched Nate navigate his surroundings independently for the first time in his life. 
But Nate’s Medicaid insurer denied coverage for a permanent power wheelchair. Fortunately, his parents turned to PHLP for assistance.
We challenged the insurer’s denial and worked with Nate’s parents and his medical team on stronger letters of medical necessity and other supporting documentation. Nate’s parents even borrowed the wheelchair a second time and took videos of Nate using the chair in his home and community to prove how beneficial it is for him. Once this new information was submitted to Nate’s insurer, they immediately overturned their denial and approved the power wheelchair. 
Nate has been using his power wheelchair for the last few weeks, and his parents report that he is happy to be on the move! 

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David Beats Goliath—PHLP Wins Final Decision Requiring Insurers To Pay for Autism Services In School 

John and Suzanne Burke knew how important it was for their seven-year-old son to receive applied behavioral analysis therapy, which medical professionals say is vital to social acclimation and development. When Independence Blue Cross (IBC) refused to pay for Anthony’s therapy in school, the Burkes called PHLP. We won!

Read more about the decision in our Health Law PA News.

Upcoming PHLP Trainings: MAWD or the Marketplace

In a series of upcoming trainings, PHLP staff will provide navigators and assisters with the eligibility criteria for Medical Assistance for Workers with Disabilities (MAWD) and help them compare health insurance options for adults with disabilities and chronic health conditions. People with disabilities and their caretakers are welcome to register as well.

The trainings will take place in the following cities:
  • Harrisburg: December 9
  • Philadelphia: December 11
  • Pittsburgh: TBA
For more information, click here.

What We're Reading

High-Cost Patients Had Substantial Rates of Leaving Medicare Advantage and Joining Traditional Medicare, Health Affairs, October 2015 (subscription required).

Each year Medicare beneficiaries can choose between two options for health coverage: traditional Medicare and Medicare Advantage. The authors found that the switching rate away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care and home health care. These results were magnified among people enrolled in both Medicare and Medicaid. The findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending.

Pediatricians Aim to Help At-Risk Kids Get Enough Food, American Academy of Pediatrics, October 23, 2015.

In the United States last year, 16 million children had limited access to adequate food because of a lack of money and other resources. Alarmed by that fact, the American Academy of Pediatrics, at its national conference, called on its doctors to take an active role in screening families for problems getting healthy food and providing resources to help, as well as taking an advocacy role in public policy to reverse the trend.

Study: Medicaid Rejecting Nearly Half of Hepatitis C Drug Requests, Philadelphia Inquirer, November 14, 2015.

State Medicaid programs in the Philadelphia region denied nearly half the coverage requests for the most effective- and expensive- treatments for chronic hepatitis C, according to a University of Pennsylvania study. The findings, based on prescription data for Pennsylvania, New Jersey, Delaware, and Maryland, appear to confirm widespread concerns that state budgets are effectively limiting treatment for a potentially fatal condition.

Commonwealth of Pennsylvania v. Eiseman, October 27, 2015, PA Supreme Court.

The Pennsylvania Supreme Court decided a pair of public records cases about payment rates for dental services under Medicaid managed care. In Eiseman I the court decided the contracts showing the rates of payments by MCOs to their dental subcontractors are "financial records" and subject to disclosure regardless of whether they contain trade secrets or confidential proprietary information. That appears to mean all medical provider payment schedules of all Medicaid MCOs should be available to anyone who files a Right-to-Know-Law request. This appears to be the first time any state Supreme Court has held that such records are public records.

Troubled Kids, Powerful Drugs: Pennsylvania Juvenile Offenders Given Psychiatric Drugs at High Rates, Pittsburgh Post-Gazette, October 25, 2015.

Pennsylvania is lagging when it comes to tracking the powerful psychiatric medications kids get in the state's youth correctional facilities, according to a PublicSource investigation that found that such medications are being given to manage mental health and behavioral symptoms at alarmingly high rates. This story opens a three-part series.

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