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PHLP eNews

July 2015

Making Summer Camp Possible for Kids with Special Health Care Needs

For nine months of the year children spend most of the day in school, and when the bell rings for the final time in June, most cannot wait to be free from daily class schedules and spend most of their time just having fun. Many (but not all) get the chance to go to summer camp. This month we worked to make sure that could happen for nine-year-old Ryan.
Ryan has cerebral palsy and traumatic brain injury. For nearly half his life he’s needed a home health aide to help him with basic tasks like getting dressed, using the restroom, and boarding the school bus. Ryan’s aide has been a consistent and necessary presence at home and school.
But this summer Ryan’s Medicaid insurer terminated all his home health services, jeopardizing his participation at the summer camp he’s attended the past two years. The loss of Ryan’s aide meant he could not attend camp because there would be no one to meet the constant physical demands of his care. But without camp Ryan was faced with a bleak landscape of things to do and might have been limited to his house, not just on the occasional afternoon or weekend, but every single day. Moreover, Ryan’s parents were desperately worried about services when the school year started, since the insurer’s decision also meant no services in September.  
Ryan’s family contacted PHLP for help challenging the insurer’s decision. Once involved, PHLP built a persuasive case to reclaim the home health aide hours by coordinating with Ryan’s physicians to prove the aide’s services are medically necessary. We also obtained an expedited hearing, since Ryan simply could not wait the normal timeframe of 1-3 months for a hearing without his aide. On the morning of the appeal hearing, before the judge even started the proceedings, the insurer agreed to overturn the denial and approve full coverage. The very next day, Ryan was at summer camp!
In September, when Ryan’s teachers ask him what he did this summer, he can say "I went to summer camp, I had a great time, and I made friends."

This is just one example of PHLP’s work protecting the rights of vulnerable Pennsylvanians. To help clients like Ryan, consider a donation to PHLP today.

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Pennsylvania's Managed Long-Term Services and Supports System: PHLP Authors Multiple Comments

Last month, Pennsylvania’s Department of Human Services (DHS) and Department of Aging (PDA) issued a discussion paper outlining their intent to deliver long-term services and supports (LTSS) through Medicaid managed care programs. These programs would receive capitated payments for LTSS and be accountable for the health and welfare of participants—seniors and persons with disabilities.  Pennsylvania is calling this proposal Managed Long Term Services and Supports (MLTSS).
Pennsylvania’s Discussion Document was purposely vague on some of the basic concepts because the state wanted to hear from people who will be required to enroll in the MLTSS program, as well as their caregivers and advocates.  Shortly after releasing the document, state officials held public hearings to provide basic information about the MLTSS initiative and to gather input from people who would be impacted by the changes—especially consumers currently receiving long-term care services.
The initial public comment period for written comments ended July 15. 

PHLP authored and joined three sets of written comments that MLTSS could result in better coordinated and integrated services for seniors and persons with disabilities, but shared significant concerns. Those comments can be found below:

Upcoming PHLP Webinars

The ACA & Family Court

Staff Attorney Joline Price will present The Impact of the Affordable Care Act on Family Court Decision-Making on Thursday, July 30th at 2:00 pm.
Find out how changes to health coverage through the Affordable Care Act impact families served by family courts, and how decisions made in those courts now impact access to health insurance. Open enrollment on starts again in November, while special enrollment periods, Medicaid and CHIP enrollment continue year round. Topics will include:
  • who qualifies for Medicaid and CHIP
  • how custody, support, and protection from abuse orders impact access to health insurance
  • how to navigate enrollment systems.
Register here:
Space is limited. Please RSVP in advance.

Older Youth with Behavioral Health Needs

Senior Attorney David Gates will present on eligibility and services for transitioning youth with behavioral health needs on Wednesday, August 19th at 1:00 pm. The webinar is sponsored by the
Pennsylvania System of Care Partnership.

The webinar can be accessed at the following link:
You can join the conference call toll free by calling (888) 744-8762 and entering access code 5698012#.

What We're Reading

HIPAA: Questions and Answers for Family Caregivers, United Hospital Fund, 2014

This guide explains HIPAA (Health Insurance Portability and Accountability Act), the federal law that protects personal medical information and recognizes the rights to relevant medical information of family caregivers and others directly involved in providing or paying for care.  

Long-Term Services and Supports for Older Americans: Risks and Financing, U.S. Department of Health and Human Services, July 2015

Most Americans underestimate the risk of developing a disability and needing long-term services and supports (LTSS).  This report estimates that about half (52%) of Americans turning 65 today will develop a disability serious enough to require LTSS, although most will need assistance for less than two years. The report also estimates the expected costs of meeting future LTSS needs, looks at the different ways those costs may be met, and identifies gaps in the way America currently pays for LTSS.  In addition, the Alliance for Health Reform recently released a toolkit focused on LTSS financing and delivery, which can be found here.

Medicaid at 50, Kaiser Family Foundation, May 2015

The Medicaid program, signed into law by President Lyndon B. Johnson on July 30, 1965, will reach its 50th anniversary this month.  The Kaiser Commission on Medicaid and the Uninsured’s report reflects on Medicaid’s accomplishments and challenges and considers the issues on the horizon that will influence the course of this major health coverage and financing program moving forward.

Marketplace Plan Selections by County in the Health Insurance Marketplace by Race & Ethnicity, U.S. Department of Health and Human Services, July 2015

Earlier this month, the U.S. Department of Health and Human Services (HHS) released new county-level enrollment data by race and ethnicity from the 37 states, including Pennsylvania, that use the federal health insurance marketplace. This level of data had never before been made available to the public. 472,697 Pennsylvanians selected a qualified health plan through the Marketplace.

We May Already Know How to Reduce the High Cost of Covering New Medicaid Enrollees, Health Affairs Blog, July 20, 2015

When negotiating their managed care contracts, many states estimated that newly eligible enrollees would cost more in the first year than non-newly eligible individuals. This approach was based on the theory that the first newly eligible people to enroll would be those previously locked out of the insurance market, quickly entering the health care system with pent-up demand. Additionally, they would be sicker and would require more health care services. But it doesn't appear to have worked that way. A 2013 study shows newly eligible Medicaid beneficiaries are healthier and less costly than the current Medicaid population. Even if the theory of the newly eligible population having pent-up demand proves to be correct, California piloted a solution that allows enrollees to receive the right care and saves money for states and the Medicaid program: care coordination.
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