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PHLP eNews

April 2016

Health Law PA News

Click here for the April 2016 Health Law PA News.

This month's Health Law PA News includes the following articles:
  • DHS Announces New HealthChoices MCOs
  • Community HealthChoices Updates
  • Pennsylvania Receives $91 Million to Serve More People in the Community
  • Pennsylvania ABLE Act Will Help People with Disabilities Keep Medicaid
  • Access to Drug and Alcohol Treatment in HealthChoices
  • Medicaid Enrollment Changes

Client Spotlight: Supporting a Mother’s Battle to Secure In-Home Care for Her Daughter

During the summer of 2015, Alyssa and her mother took a trip to California to celebrate college graduation. On the way home, Alyssa suffered a sudden cardiac arrest which resulted in a severe brain injury and left her completely dependent on caregivers to meet her most basic daily needs. For nearly a year after the injury, Alyssa’s private health insurance plan covered in-home nursing care which allowed her to remain at home, rather than moving into a nursing home away from her mother and everything familiar to her. When Alyssa’s mother received notice that her insurance would no longer cover that care, she applied for a Medicaid program (known as a Waiver) which, if approved, would allow Alyssa to continue receiving the supports and services she needed. Unfortunately, Alyssa’s Waiver application was denied based on the reviewer’s assessment that her needs were too great to allow her to be safely cared for at home.  

However, Alyssa's mother knew how much progress her daughter had made with in-home nursing and that continuing that level of care would be best for her daughter. She filed an appeal to challenge the denial and called PHLP for help.

PHLP provided a point-by-point summary of advice for the hearing. We recommended that Alyssa’s doctor and nursing agency participate to communicate Alyssa’s positive changes over time. The judge saw that contrary to the assessment, Alyssa was not in a vegetative mental state, and he overturned the denial. 

Alyssa’s mom expressed her gratitude to us, emphasizing the importance of PHLP’s guidance: “God was listening, and thanks to you, I came prepared and the only document I made reference to was of all of her improvements since she has been home, of which you advised me to do.”

Alyssa’s mom recently wrote to us to share her story.

"I was there fighting to keep my daughter home and argue with the State that my daughter would be better served at home, and I had all of the documentation to show how far she has come since she has been home.

"All doctors in the beginning told me to pray for a miracle, that they had no hope of recovery. Had I not taken my daughter home so she could be in a loving, nurturing and caring environment, they probably would have been right. My daughter would have been kept heavily medicated since no one really took the time to 'think' of a plan of care to help my daughter recover. They just focused on the ‘pain’ side, and not really trying to figure out why there was pain. It was my constant monitoring, asking of many questions, that eliminated many of the medications and brought her to where she is now, stable, awake, alert, and responding to stimuli. The Johns Hopkins doctors (who we waited 8 months on a list to see) are now telling me that they have hope of recovery.

"Never give up hope. Never stop fighting for what you believe is right... Everything has been a battle for me, but I have patience and never will I give up. Finally, things are starting to fall into place and I am getting the services and equipment that my daughter needs. If you can, please take your loved one home and care for them."

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What We're Reading

Can Telemedicine Help Address Concerns with Network Adequacy? Opportunities and Challenges in Six States, Urban Institute, April 2016

Health plans have been increasingly narrowing their provider networks, raising concerns about gaps in access to services for consumers, particularly in areas with provider shortages. Could telemedicine be used to help fill those gaps? Through a review of state regulations and interviews with key stakeholders, including insurance companies, regulators, and medical providers in six states (Arkansas, Colorado, Illinois, Maine, Texas, and Washington), this paper finds that while telemedicine can increase access to services, it is unlikely to be used as tool to meet network adequacy standards any time soon.

President’s Task Force Aims to Help End Discrimination in Mental Health Coverage, Kaiser Health News, March 31, 2016

President Obama announced the creation of a task force on mental health parity — aimed at ensuring that people with mental illnesses and substance abuse problems don’t face discrimination in the health care system. “The goal of the task force is to essentially develop a set of tools, guidelines, mechanisms so that it’s actually enforced, that the concept is not just a phrase — an empty phrase,” Obama said during a panel discussion at the National Prescription Drug Abuse and Heroin Summit in Atlanta, Georgia. “We’ve got to let the insurance carriers know that we’re serious about this.”

The announcement comes the same week as the Centers for Medicare and Medicaid Services released a final rule requiring that the millions of beneficiaries who receive services through Medicaid managed care organizations, Medicaid alternative benefit plans, or CHIP be provided access to the same mental health and substance use disorder benefits and protections of private plans.

Civil Rights Laws as Tools to Advance Health in the Twenty-First Century, Annual Review of Public Health Vol. 37: 185-204, March 2016 (subscription required)

Our colleagues at NHeLP discuss strategic ways to use civil rights laws to promote both access to and quality of health care services and delivery, and to address health disparities. The article is part of an issue suggesting ways to improve health and equity broadly, especially within societal groups and marginalized populations, including approaches that address the social determinants of health.

Facilitating Successful Re-Entry For Individuals Transitioning From Incarceration To Their Communities, Centers for Medicare & Medicaid Services, SHO # 16-007 (April 28, 2016)

This release by the federal government provides guidance to states on facilitating access to covered Medicaid services for eligible individuals prior to and after a stay in a correctional institution. It includes a Questions and Answers format that describe how states can better facilitate access to Medicaid services for individuals transitioning from incarceration to their communities.  A recent story about health care for released offenders by WHYY highlights the importance of the guidance.
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