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PHLP eNews

January 2015

Client Spotlight: PHLP Secures Important Follow-up Test for Cancer Survivor

For cancer survivors, regular imaging tests—e.g., positron emission tomography (PET) scans—are critical to follow-up care after treatment. In the event that the cancer returns, these scans can detect it so that it can be treated right away.

Ruth had already battled thyroid cancer once. Her doctors worried about her cancer recurring and advised her to have a PET scan, but her health plan denied the claim for the scan. Troubled by the denial, she contacted PHLP for help with her next battle.

PHLP instructed Ruth to immediately appeal her health plan’s denial of the PET scan, and began working with Ruth’s doctor to create a compelling letter that contained both clinical information and persuasive language on the medical necessity standard. This new letter was submitted to the insurance plan. PHLP also walked Ruth through the steps of representing herself at her grievance, giving her advice and a confidence boost.  

Finally, the health plan reversed their denial. The PET scan would be approved! Ruth was very pleased with the outcome and was extremely grateful for the assistance she received from PHLP. Now, she can focus on working with her doctors to ensure her continued health.

To help clients like Ruth, consider donating to PHLP today. 

Donate to PHLP

PHLP Releases Immigrant Health Care Manual

PHLP has updated its manual on Immigrant Health Care in Pennsylvania. Intended to assist health care advocates who work with immigrant populations, this manual describes the various forms of publicly-funded health coverage and services available to immigrants in Pennsylvania, including Medicaid Assistance (or Medicaid), Emergency Medical Assistance (EMA), non-insurance options like community health centers, and new information related to Marketplace coverage for immigrants. Readers will learn immigration status requirements for various forms of public health programs and will also receive practical tips on how to advocate for immigrant clients seeking health care coverage and services in Pennsylvania. 

The updated Medical Assistance Eligibility Manual can be found

Updated PHLP Resource

Medical Assistance for Workers with Disabilities: A Guide to Eligibility, January 2015

PHLP in the News

Applying for PA Medicaid Expansion? Wait in Line, The Philadelphia Inquirer, January 15, 2015

What We're Reading

Integrated Appeals Processes for Medicare-Medicaid Enrollees: Lessons from States, Center for Health Care Strategies (January 2015) & Due Process in Duals Demonstrations: A Closer Look at New York, National Health Law Program (November 2014)

Medicare and Medicaid appeals processes are significantly different, creating challenges for states in aligning them in new integrated models of care. These two briefs present lessons for achieving greater alignment in appeals processes for Medicare-Medicaid enrollees in capitated health plan arrangements, either through a Dual Eligible Special Needs Plan (D-SNP) or as part of a financial alignment demonstration (e.g., New York).  

Appointment Availability After Increases in Medicaid Payments for Primary Care, New England Journal of Medicine, January 2015

A key provision of the Affordable Care Act was to significantly raise Medicaid reimbursement for primary care in 2013 and 2014. The goal of the higher-pay-period was to expand access to primary care for the growing number of Medicaid enrollees. It worked, especially in Pennsylvania!  A new study published in the New England Journal of Medicine reports trained workers posing as patients in calls to physicians who accepted Medicaid scheduled appointments more often than before the “Medicaid payment bump.”  Pennsylvania, which had reimbursed Medicaid doctors at some of the lowest rates in the country, was a prime example of success: appointment availability increased by close to 13 percentage points.  Because of Congressional inaction, the federally funded payment increase expired December 31, 2014. The Urban Institute reports that means Medicaid primary care fees in Pennsylvania will fall by 50 percent or more.

New Rules to Limit Tactics on Hospitals’ Fee Collections, December 2014

Just before the New Year, the Treasury Department and IRS issued long-awaited final rules that discourage nonprofit hospitals from using aggressive methods to collect payments from low-income patients. The regulations set a new federal floor that increases transparency on financial assistance and collections, provides some protection against medical debt and overcharging, and offers communities greater insight and potential influence on the way hospitals understand and address broader health issues. See also a January NY Times article describing the new rule.  

Modern Era Medicaid: Findings From a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP as of January 2015, Georgetown University Center for Children and Families and Kaiser Family Foundation, January 2015

This report reveals that PA is:
  • 1 of 6 states with a CHIP buy in program that allows families to purchase CHIP at full cost if family income is above 319% of poverty
  • 1 of 33 states that cover pregnant women above 200%
  • 1 of 21 states that have eliminated the waiting period for CHIP coverage
  • 1 of 28 states that allow lawfully residing children to enroll in Medicaid or CHIP without imposing a 5 year waiting period and 1 of 23 with no 5 year waiting period for pregnant women
  • 1 of 12 states that provide Medicaid coverage to former foster youth who were in foster care in any state

*Inclusion in "What We're Reading" does not imply endorsement and views expressed here do not necessarily represent the views of PHLP
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