PHLP Releases Medical Assistance Eligibility Manual
PHLP has expanded and updated its Medical Assistance Eligibility Manual. Intended for health care advocates and the general public, this manual describes eligibility for Pennsylvania’s Medicaid Assistance (or Medicaid) program in plain language. Readers will learn Medicaid coverage "categories" as well as the program’s income and resource counting rules.
The updated Medical Assistance Eligibility Manual can be found here.
As 2014 comes to an end, PHLP would like to thank all of our supporters. With your help, we secured health care for over 5,000 low income persons and those who are otherwise vulnerable.
Please consider us when you are making any year-end contributions to charitable organizations. Donations can be made by mail or by using our secure online form at secure.donationpay.org/phlp.
We wish you happy holidays and good health in the coming year!
Client Spotlight: Healthcare.gov Hiccup Leaves a Family Without Essential Coverage
Julie from Chester County called PHLP in a panic when she was left without coverage for a week due to an error on the Health Insurance Marketplace. She has Type 1 Diabetes and had been without insulin all week while trying to get her coverage reinstated.
In 2014, Julie and her family had been covered through a Marketplace plan. On the first day of 2015 Open Enrollment, Julie visited www.healthcare.gov to update her plan (it was not being offered in 2015) and her family’s financial information, as they received premium tax credits and cost-sharing subsidies to help pay for their coverage.
When Julie selected a 2015 plan offered by her insurer, her current 2014 coverage was deleted! Upon being notified of the erroneous cancellation, the insurer placed Julie's family in a different plan to give them coverage for the last month of the year. However, the new plan had a deductible of $500. Julie’s family had already met their annual deductible through their old plan. The new deductible was causing problems in accessing necessities such as medication because they couldn’t afford to meet another deductible.
To complicate matters, the family’s income was below 138% of the federal poverty level (FPL), and they would qualify under Medicaid expansion beginning January 1, 2015 in Pennsylvania. An individual with Marketplace coverage in 2014 whose income is under this limit is flagged bywww.healthcare.govwhen renewing Marketplace coverage for 2015, and the system tells them to apply for Medicaid. Since Julie visited the Marketplace on the first day of Open Enrollment, it was not yet updated to flag individuals potentially eligible under expansion. She was unaware of this new program, and if she didn’t proceed with applying for Medicaid coverage, she might face tax consequences at the end of 2015 and have to pay back any financial help received to pay for the Marketplace plan.
PHLP reached out to Julie’s insurer to explain what happened, urging them to reinstate the coverage she had before since it should not have been terminated early. By the end of the day, her coverage was reinstated and she was able to get her health-sustaining medication! PHLP also advised her on applying for Medicaid since it seemed her family was in the newly eligible adult group. Although Julie’s coverage termination was inappropriate and possibly illegal, PHLP was able to engage in advocacy outside of the legal system to get a quick, positive result for Julie’s family.
To help clients like Julie, consider donating to PHLP today.
This report follows up an earlier reportdocumenting wide variation in state Medicaid managed care network adequacy standards and generally lax oversight of those standards. The new report revealed of 1,800 primary care providers and specialists surveyed, 51 percent were not available to schedule appointments, either due to an incorrect location listed in the plan directory (35%), denying participation in the listed plan (8%) or refusing to accept new patients (8%). The survey also measured average wait times for successful appointments (2 weeks), but found much longer wait times for some providers. Specialists were generally more likely to offer appointments than primary care providers, but also had longer wait times to schedule an appointment.
A New York Timesarticle summarizes the findings and notes that federal officials will be promulgating new Medicaid managed care regulations to address some of the problems identified by OIG.
There are some markets where consumers tend to stick with the same market choice forever, even though switching could save them quite a bit of money. Energy bills are a classic example. We’ve long been told we can save money by leaving incumbent providers for newer upstarts, but the vast majority of us haven’t. Economists call it consumer inertia, and you can see it in many fields, including banking, credit cards, and health insurance.
A state's decision to forgo Medicaid expansion affects the staying power of hospitals in rural areas. Families USA created an infographic comparing recent rural hospital closures in Medicaid expansion states against closures in states that have not expanded Medicaid. In Pennsylvania, which did not expand Medicaid until 2015, there were two rural hospital closures.
*Inclusion in "What We're Reading" does not imply endorsement and views expressed here do not necessarily represent the views of PHLP