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PHLP eNews

July 2016

Health Law PA News

Click here for the July 2016 Health Law PA News.

This month's edition includes the following articles:
  • DHS Cancels Current HealthChoices Procurement
  • Fiscal Year 2016-2017 Budget Enacted
  • Update on Suspension of Medicaid Benefits While Incarcerated
  • Attention Fee-For-Service Consumers: Make Sure Your Prescribing Doctors are Enrolled in Medicaid, Or Else Medicaid Will Not Pay
  • Pricey Hepatitis C Drugs a Tough Pill for DHS to Swallow
  • Task Force Formed to Address Barriers to Substance Abuse Treatment in PA
  • Update on Funding for APPRISE

Helping Single Moms Get the Medical
Support They Need for Their Children

Watching two young children by yourself can be challenging for any parent. When one of those children has special medical needs, it is almost impossible without extra support.

Parents, especially single moms like Emma, know this well. Emma’s 3-year-old son Luke was born with severe birth defects affecting his face and internal organs which make it impossible for him to eat or breathe normally. As a result, he has an artificial airway and gets much of his nutrition through a feeding tube. Fortunately, Luke’s family has not been alone. Since he was born, skilled nurses have been helping Emma monitor his airway 24-7, administer his feedings, and maintain all of his medical equipment.

But when Luke’s Medicaid insurer decided to cut his daytime nursing hours in half, Emma was faced with being the lone caregiver for both Luke, with all his medical needs, and his energetic 5-year-old sister, for 12 hours a day. If the nursing cuts went through, Emma would also have to quit work to care for Luke. Fortunately, Luke’s nursing case manager encouraged Emma to contact PHLP for help challenging the insurer’s denial.

While reviewing Luke’s case, PHLP staff realized that the insurance company’s denial letter failed to explain why Luke’s hours were being cut, making it extremely difficult to prepare an appeal.  PHLP immediately contacted the Department of Human Services, which oversees Medicaid insurers, and got the insurance company to issue a new letter disclosing its reasons for cutting Luke’s nursing hours.

In its new denial letter, the insurance company claimed the extra hours were not needed because Luke’s mother was available to care for him during the day. PHLP staff was undeterred and helped Emma document her working hours so she could explain why her responsibilities inside and outside the home make it impossible for her to safely care for Luke 12 hours per day. That guidance and counsel was compelling and made the difference.  The insurance company reversed its denial and allowed Luke to keep his current nursing hours.

Thanks to PHLP, Luke and his family will continue getting the in-home nursing support they need.

If you would like to ensure that families like Luke’s can successfully challenge insurance companies, consider a donation to PHLP today. 

Donate to PHLP

What We're Reading

Mis-Managed Care: Fair Hearing Decisions on Medicaid Home Care Reductions by Managed Long Term Care Plans, Medicaid Matters New York (MMNY) and National Academy of Elder Law Attorneys, NY Chapter (NY NAELA), July 2016

In 2015, advocates who represent NY residents enrolled in Medicaid Managed Long Term Care (MLTC) plans observed a sharp increase in the number of clients reporting that their MLTC plans had sought to reduce their home care services. This increase in cases raised concerns about whether these reductions violated the rights of plan members. Advocates undertook this study to examine the prevalence and extent of reductions by MLTC plans, and to assess plan compliance with procedural requirements for reducing hours of care. 

A review of all of the hearings in which decisions were issued overturning the threatened reduction reveals a systemic pattern of reductions unjustified under Mayer v Wing, a federal court decision implemented by New York State regulations. This case, based on fundamental constitutional principles of due process, prohibits a reduction in Medicaid home care services unless the agency establishes a change in medical condition or other circumstances that make the hours previously authorized unnecessary. In decision after decision, Administrative law judges found that the MLTC plans failed to sustain their burden of proof to establish any such justification.
Lives Upended by Disputed Cuts in Home-Health Care for Disabled Patients, NYTimes, July 20, 2016

A compelling article describing one of the NY residents profiled in the Mis-Managed Care report described above.  “Widowed and disabled after a lifetime of New York factory work, including decades making baby dolls with glue that proved to be toxic, Alejandra Negron depends on a little help for nearly every step she takes. For years, she has had just enough help to stay safely in her own tidy one-bedroom apartment in Manhattan, despite pulmonary disease, asthma, diabetes, arthritis and a heart condition.

“Medicaid, the state and federal health care program for the poor, covers the cost of a home-care aide during the day, and Ms. Negron’s two daughters and a granddaughter take turns staying over at night and on weekends, despite their own jobs and family obligations.
“But last winter, that carefully stitched web of caregiving was abruptly torn apart by a call from Senior Health Partners of Healthfirst, a managed care insurance company that has been one of the beneficiaries of Medicaid’s overhaul of long-term care for disabled and aged people in New York. The company informed Ms. Negron that her home care was immediately being cut to 25 hours a week from 50…”
Closing the Equity Gap in Health Care for Black Americans, Commonwealth Fund, July 15, 2016

“As Americans focus on troubling racial divisions in the country’s criminal justice system, we should not forget that those divisions exist in other areas of our national experience. One is health care."

“The U.S. health care system does not perform well for black Americans. On average they experience worse access to care, lower quality of care, and poorer health outcomes than the nation as a whole…”

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