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PHLP eNews

September 2014

Client Spotlight: Securing a Power Wheelchair Allows Consumer to Remain at Home

When you are living with a disability, durable medical equipment makes daily activities—like getting in and out of bed—much easier. But acquiring such equipment from a health insurer is challenging. PHLP intervenes when a person’s health and safety is significantly compromised by the insurer's denial. “Agnes,” a PHLP client with multiple sclerosis, needed a new power wheelchair to navigate her home. Without one, she risked serious injury every time she used the bathroom or got out of bed because Agnes’ arm strength was not great enough to support her weight when performing those tasks.

Agnes’s doctors requested a power wheelchair with a seat elevator, which would allow Agnes to move vertically as well as horizontally so she could do these activities. However, Agnes’s health insurer denied the request.

PHLP successfully represented Agnes in her appeal. She prevailed because at the grievance hearing, PHLP presented detailed testimony that a power wheelchair with a seat elevator was medically necessary and explained it would help her significantly. Agnes continues to live independently, completing daily activities more easily and without putting her personal safety at risk.

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

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PHLP Pleased About Medicaid Expansion, But Concerned About Its Implementation


Last month, the federal Centers for Medicare & Medicaid Services (CMS) approved Governor Corbett’s Healthy Pennsylvania proposal, making Pennsylvania the 27th state to expand Medicaid under the Affordable Care Act (ACA). State officials describe the program as a Pennsylvania-specific solution. This is a new pathway for an estimated 600,000 low-income, uninsured adults to gain coverage beginning in January 2015.
 
PHLP is pleased so many uninsured Pennsylvanians can qualify for health coverage in January 2015, and that the approved plan does not eliminate certain Medicaid protections for the newly eligible like appeal rights and retroactive coverage. However, we have concerns:
 
1.
High premiums will cause loss of coverage. A significant body of research shows that premiums for low-income people result in loss of coverage, unmet health care needs, and adverse health outcomes. Despite the research, Pennsylvania will impose the highest Medicaid premiums of any state in the country beginning in 2016.
 
2. The new delivery system creates bureaucratic hurdles for Medicaid recipients. The new Medicaid managed care system will operate separately from the existing Medicaid system and the Federally Facilitated Marketplace, and recipients will have to move among the systems as their circumstances change. Pennsylvania has a history of difficulties in linking health systems, like the Medicaid system, CHIP system, and Federally Facilitated Marketplace for children, and the Medicaid system and the Federally Facilitated Marketplace for adults. Recipients may experience coverage disruptions as they “churn” among systems. Moreover, a new system will create administrative complexity and expense, burdening applicants and recipients, DPW staff, and taxpayers.
 
PHLP is preparing in-depth trainings for consumer advocates about the implementation of these new coverage pathways. We will release the training schedule soon. In addition, PHLP will be monitoring Pennsylvania’s implementation to ensure applicants quickly receive the healthcare they desperately need and lawfully deserve.      

What We're Reading



State Strategies for Integrating Physical and Behavioral Health Services in a Changing Medicaid Environment, the Commonwealth Fund, August 2014 (a report that explores strategies states are deploying to address or eliminate system-level barriers to integrated care for this medically complex and high-cost Medicaid population)

The State of Children's Health Care in Pennsylvania, Pennsylvania Partnerships for Children, Fall 2014 (finding that despite Pennsylvania's longstanding status as a state of "universal coverage" for all documented children, the commonwealth is home to more than 144,000 children who lack health insurance)

Fate of Children's Health Insurance Program is Called into Question at Senate Hearing, New York Times, September 16, 2014


Letter from Medicaid Health Plans of America (MHPA) to Centers for Medicare & Medicaid Services (CMS) Director Cindy Mann, September 4, 2014 (providing recommendations for regulatory updates)

Lawsuit Says CA Puts Lives at Risk by Leaving Hundreds of Thousands in Medi-Cal Limbo, National Health Law Program, September 17, 2014 (describing a lawsuit brought by a coalition of legal services organizations and community healthcare advocates accusing California of leaving hundreds of thousands of low-income applicants to wait for months without the healthcare they desperately need and lawfully deserve)

How to Reboot Healthcare.gov, New Republic, September 17, 2014

Low-Wage Workers Feel the Pinch on Health Insurance, Wall Street Journal, September 18, 2014

* 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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