PHLP Helps 9-Year-Old Isaac Receive Necessary Surgery
Nine-year-old Isaac from York County was born with a cleft lip. Treatment began during Isaac’s infancy and needs to continue through early adulthood. A few months ago, Isaac’s doctor at Johns Hopkins in Maryland recommended follow-up surgery. While Isaac’s primary insurance agreed to cover 80% of the surgery, his secondary insurance, a Gateway Medical Assistance plan, denied the request. The denial letter stated that the surgery should take place at an in-network hospital rather than at Johns Hopkins Hospital. Isaac's family decided to appeal the denial, because they live four hours away from the nearest in-network hospital and Johns Hopkins had performed all of Isaac’s other related surgeries. At a first level grievance hearing, Gateway upheld its denial. However, his mom continued to fight. She filed a second level grievance and turned to PHLP for guidance.
PHLP reviewed the letter of medical necessity written by Isaac’s surgeon, noting that the letter did not adequately explain why the surgery should occur at Johns Hopkins. PHLP advised Isaac’s mother on how to work with the surgeon to craft a stronger letter. Armed with this new information, Isaac’s family successfully argued their case of medical necessity, and Gateway approved the request. Isaac was then able to receive the necessary surgery at Johns Hopkins.
Isaac’s case shows that continuing medically necessary services with a competent, trusted medical provider do not come easily, even to the most vulnerable, and underscores the value of competent counsel to improve the health of Pennsylvania’s children.
PHLP Offers Families Practical Guidance About Children’s Medicaid Co-Pays; State Drops Plan
At the end of September, tens of thousands of families who have children with disabilities opened their mailboxes to find a letter from the Department of Public Welfare (DPW) announcing collection of co-payments. Legislation passed last year (Act 22 of 2011
) required the implementation of Medical Assistance (MA) co-payments for children with disabilities whose family income exceeds 200 percent of the poverty level, which is $46,100 a year for a family of four. Many of these families immediately reached out to PHLP to learn more about their options and rights. They felt the amounts they would be expected to pay were excessive, and some said DPW miscalculated their household incomes, which determined how much a family would have to pay.
In response to an overwhelming number of calls and general confusion, PHLP partnered with the Parent Education and Advocacy Leadership (PEAL) Center
to provide a free webinar. PHLP Senior Attorney David Gates and PHLP Special Projects Director Ann Bacharach organized the October 5th
training, explaining the latest changes to co-payments, what remains to be clarified, and what responsibilities and appeal rights families have. More than 1,000 individuals registered.
Towards the end of the webinar, PHLP announced breaking news: DPW would delay
the co-pay initiative, and instead seek approval from the federal government to charge a premium to affected families. PHLP developed a frequently asked question sheet of follow-up questions that can be viewed here
and on PEAL’s website.
PHLP Conducting Free Trainings on Changes to Medicare Part D in 2013
The Annual Enrollment Period opened Monday October 15th
for Medicare beneficiaries. During this seven-week window (from October 15, 2012 to December 07, 2012) any beneficiary can choose for the first time or can change their Medicare Part D prescription coverage and/or their Medicare Advantage Plan. Any enrollments made during this period will become effective January 1, 2013. Annual changes to plan coverage and costs make choosing the right plan difficult, and often frustrating.
During the months of October and November, PHLP will host four in-person trainings in Southwestern Pennsylvania as well as two webinar trainings to discuss what consumers, providers, and advocates need to know about Medicare in 2013. These are free trainings for consumers, providers, and advocates.
Attendees will learn about:
Click here to learn more about these free trainings and how to register.
2013 Part D Plan Costs and Options;
Changes to the definition of Part D covered drugs (to include benzodiazepines and certain barbiturates);
Enrollment periods and notices consumers receive in the fall; and
Other developments affecting low-income Medicare beneficiaries (such as, Medicaid changes affecting dual eligibles).