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PHLP eNews

October 2016

Health Law PA News

Click here for the October 2016 Health Law PA News.

This month's edition includes the following articles:
  • Legislative Hearing Focuses On Waiver Enrollment Problems
  • Community Health Choices Updates
  • People on Medicare Should Be on the Lookout For These Mailings!
  • PHLP Offers Medicare 2017 Webinar
  • Coverage of Diabetic Testing Supplies for Dual Eligibles
  • Governor Wolf Issues Guidance for Consumers and Health Plans on Parity in Mental Health and Substance Use Disorder Coverage
  • Marketplace Open Enrollment Starts November 1st!
  • REMINDER: “One Set Per Lifetime” Dentures Limit Reset Last Year

Sorting Out Who Pays (Medicare or Medicaid) For Anti-Rejection Meds for a Transplant Recipient

Navigating health insurance can be confusing for people who are dual eligible. Note: Dual eligibility refers to older adults and people with disabilities who have limited income and resources and qualify for both Medicare and Medicaid coverage. Janet, a 47-year-old living in Washington County, knows this frustration all too well. Janet had a kidney transplant almost 30 years ago and still takes multiple anti-rejection medications. She only receives $900/month from Social Security Disability and her medication was costing almost $100. Concerned, Janet reached out to PHLP.

PHLP realized that her medication shouldn’t cost anywhere near this amount and quickly set to work to get this problem resolved for Janet so she could get this important medication.  Janet had a Medicare Advantage plan for dual eligibles. Because Janet had Medicare at the time of her kidney transplant, the anti-rejection medications are covered under Medicare Part B instead of Medicare Part D. Her Medicare Advantage plan should have paid for it under the Part B medical benefit as required for her situation. PHLP contacted Janet’s pharmacy to see if they had billed her Medicaid coverage for the Part B coinsurance amount. The pharmacist said they did but it was not going through, and he was not clear why.

PHLP then reached out to staff in the pharmacy department at the Pennsylvania Department of Human Services to find out why the ACCESS card was not covering the remaining cost of the anti-rejection medication. DHS staff said the pharmacy needed to call their hotline and confirm that Janet’s insurance covered the medication under Medicare Part B (not Medicare Part D) and then staff could enter an override for the ACCESS card to cover the medication. PHLP relayed this information to the pharmacy and they made the needed call. Janet was then able to get her anti-rejection medication for a small Medicaid co-pay ($1.00)! She was thrilled and relieved that she would be able to get these vital medications at a price she could afford!


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PHLP in the News

PHLP has been working with Pennsylvania Health Access Network (PHAN), Project H.O.M.E., and the Housing Alliance of Pennsylvania. The Housing as Health Campaign takes a more collaborative approach to public health, lobbying for housing for Medicaid-specific patient homes. The goal is to create a continuity of care in Pennsylvania’s most vulnerable populations, which would decrease costs and improve quality of care. Read more about the Housing as Health Campaign here.

What We're Reading

The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid, Rachel Garfield and Anthony Damico, The Kaiser Family Foundation, October 19, 2016

“As of September 2016, 19 states had not expanded their programs. Medicaid eligibility for adults in states that did not expand their programs is quite limited: the median income limit for parents in 2016 is just 44% of poverty, or an annual income of $8,870 a year for a family of three, and in nearly all states not expanding, childless adults remain ineligible. Further, because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other coverage options. As a result, in states that do not expand Medicaid, many adults fall into a “coverage gap” of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits.”

Massive health collaboration launched in North Philly, Harold Brubaker,, October 20, 2016

“Pennsylvania officials announced Thursday a broad collaboration to improve health care in North Philadelphia and a swath of surrounding neighborhoods where at least half the residents receive Medicaid, costing more than $1 billion last year… It is home to five hospitals that struggle financially under a heavy load of Medicaid patients.”

More Pennsylvania residents have insurance, Kate Giammarise, Pittsburgh Post-Gazette, October 13, 2016

With the expansion of Medicaid, uninsured rates have dropped for both children and adults.

“Census data show the uninsured rate among Pennsylvanians was 8.5 percent in 2014, dropping to 6.4 percent in 2015, meaning about 802,000 people remain uninsured.”

Officials Warn Some Older Marketplace Customers To Switch To Medicare, Susan Jaffe, Kaiser Health News, October 14, 2016

“And last month, CMS also began sending letters to people already covered by Medicare but also enrolled on the marketplace and getting financial assistance. The letters, required under the federal health law, say they can keep dual coverage — without subsides — but urges them to discontinue their marketplace policy, since in most cases it duplicates their Medicare benefits. If marketplace enrollees don’t respond, eventually officials can cancel the subsidies.”

Medicaid [in South Carolina] Finds Opportune Time to Offer Birth Control: Right After Birth, Sabrina Tavernise, NY Times, October 28, 2016

“[C]ontraceptive methods have never been better: Tiny implants and new, modern IUDs last for up to five years and are far more effective than condoms and the pill. The problem is that they are expensive and usually require several trips to the doctor, insurmountable hurdles for many low-income women.

 “The idea behind [South Carolina’s] policy is to seize the day when a woman is sure to be interacting with the health care system — at the birth of a child. It is also the moment she is most likely to be insured: Pregnant women who are poor and do not have insurance are put on Medicaid temporarily. Birth control is usually discussed in a checkup about six weeks after delivery, but a majority of women on Medicaid, which covers 57 percent of births in South Carolina, do not return, officials said. Nearly half of all births in the United States are covered by Medicaid.

 “Taking note of the success that the South Carolina Medicaid office has had in boosting the use of long-acting contraceptives, the biggest private insurer in the state, Blue Cross Blue Shield, has started offering the same option to women who have just given birth. Nineteen other states — including Georgia, Iowa, Maryland, Massachusetts and Texas — have since made similar policy changes, according to the American Congress of Obstetricians and Gynecologists. This summer, the group recommended that other states do the same.”

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