Pennsylvania Health Law Project: Helping People in Need Get the Health Care They Deserve
Appeal Victory: PHLP Helps 28-Year-Old Retain Crucial In-Home Supports

Last week, PHLP won an administrative appeal that kept needed services in place for a 28-year-old man, Ira,with complex health needs, including Down Syndrome, heart problems, ADHD, and compulsive behavior issues. For years, Ira received skilled care and supervision through the Consolidated Waiver, which allowed him to thrive. But when the County Office of Intellectual Disability Services (IDS) reduced the level of services Ira had been receiving, Ira gained weight, his ability to communicate regressed, and he experienced a marked increase in self-destructive behaviors.

Ira’s mother appealed the IDS decision on her own, and the appeal was denied. Ira’s parents then went to court, but when it was discovered that the tapes from the initial appeal’s administrative hearing were inaudible, a new hearing was scheduled. At this point, Ira’s mother called the PHLP Helpline for advice.

Picture of Ira
PHLP determined that critical information and facts had not been considered at the first hearing, and that the service reduction had been based on an erroneous understanding of the nature of the services. At the second hearing, PHLP represented Ira. The Administrative Law Judge, who had denied Ira’s appeal at the first hearing, reversed himself after the second hearing, finding in Ira’s favor based on the testimony, evidence, and legal arguments presented by PHLP. Ira will now be able to keep his skilled aides who have done so much to improve his health, behavior, communication skills and general well-being.

PHLP Survey Reveals Provider Co-Payments Will Burden Families of Children with Special Health Care Needs

As part of the 2011-12 state budget, the Pennsylvania Department of Public Welfare was directed to impose co-payments for Medicaid services on children with special health care needs whose family income is more than 200% of the federal poverty guidelines.  PHLP and several partners (Disability Rights NetworkMental Health Association in PA, the PA Chapter of the American Academy of PediatricsPennsylvania Partnerships for Childrenand PA Community Providers Association)  are working to ensure that this imposition does not place too great a financial and administrative burden on families. As part of that effort, PHLP surveyed 948 families about what services they use, what out-of-pocket expenses they pay, and how Medicaid services support their children in school. 

Highlights of the responses are available here.

PHLP and its partners have developed a set of recommendations to DPW on how to best implement the co-payments and will meet with DPW staff later this month. For more information contact David Gates at

Save the Date: PHLP Webinars to Highlight Changes to Medicare Part D

PHLP is conducting two online information sessions on upcoming changes to Medicare Part D in 2012. Topics include:
  • Annual Enrollment Period moves earlier: now October 15th to December 7th
  • Part D co-pays eliminated for Home and Community Based Services (HCBS) Waiver recipients in 2012
  • Special Enrollment Period to join a 5 Star Plan
  • Part D plan options and costs changing
  • Other developments affecting low-income Medicare beneficiaries (i.e., Medical Assistance changes affecting dual eligibles)
The sessions are scheduled for Thursday, November 3rd at 1pm and Thursday, November 10th at 3pm. An e-mail announcement with details on registration will follow. 
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PHLP in The News

Federal Health Reform Will Help Consumers, Small Firms, Laval Miller-Wilson, Legal Intelligencer, 10/3/11 [subscription required]

What We're Reading

Health Reform GPS: Navigating Implementation

Ten Ways to Make Health Coverage Enrollment and Renewal Easy, Enroll America, August 2011

A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50-State Survey, Kaiser Commission on Medicaid and the Uninsured, September 2011

Refocusing Responsibility for Dual Eligibles: Why Medicare Should Take the Lead
, Robert Wood Johnson Foundation, October 2011

Building an Integrated Appeals System for Dual Eligibles, National Senior Citizens Law Center, October 2011
State Options That Expand Access to Medicaid Home and Community-Based Services, Kaiser Commission on Medicaid and the Uninsured, October 2011
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The Pennsylvania Health Law Project is a nationally recognized expert and consultant on access to health care for low-income consumers, the elderly, and persons with disabilities. PHLP engages in direct advocacy on behalf of individual consumers while working on the kinds of health policy changes that promise the most to the Pennsylvanians in greatest need.
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