Posts tagged 'Medicaid Benefits'
As the saying goes, stuff rolls down hill. In the situation with all the budget constraints on the federal government, comes constraints on the state and local government. Healthcare is definietly no exception. Lawmakers in Washington are looking at some very deep cuts when it comes to many programs and trying to figure out how to keep them from being deeper than they already are.
One of the programs that is being looked at piece by piece and line by line is Medicare. There will definitely be cuts to that program, period. As a result, as things roll down hill, Medicaid, which is a state program but bolstered by federal dollars, is taking a big hit, too.
Not only are some Medicaid benefits being cut way back, but getting into the program, which is already on the difficult side, has become much tougher indeed. It seems as though unless you are in the most dire straits getting approved for Medicaid is extremely difficult. Even if you are in dire straits and the rope you are hanging onto is beginning to fray - a lot - it is still difficult to get approved.
Consider the case of a 60 year old woman who was disabled in an accident. Her doctors took her off work indefinitely and she has no income except for $200 of assistance money which will run out very soon because of the new cuts from 18 months down to 12. She has no money to go to the doctor and has applied for Medicaid. She suffered injuries in the accident - which happened at work - but Worker's Comp is fighting against paying because she had some pre-existing conditions. Of course, what 60 year old man or woman doesn't? Meanwhile, she is in constant pain, in need of surgery and walking around on crutches or a cane with a fractured hip and two badly injured knees just for starters. She has high blood pressure (which has sent her to the ER 6 times in 3 months because it was at stroke level or higher), osteoporosis, arthritis, degenerative disc disease and possibly diabetes. She has doctor's letters, medical records and more that were sent to Medicaid. She applied for Medicaid and was turned down.
This individual did everything by the book and is having to go through hoops all over again trying to get help. This is before the new budget cuts that are on the way.
This is not to say that Medicaid is unfair or that it is a bad program. It is a good program and was designed for people like this 60 year old lady who has fallen through the cracks - badly. Each state deals with their own Medicaid program so it can be a little easier or a little harder depending on the state a person is in. Even if you have all your ducks, doctor's notes and medical information in a row, it can be tough to get Medicaid.
Do not give up, re-apply, call and talk to your worker and do whatever is necessary to give them the information so that you will get approved. Eventually, most people do get approved. It is simply a tedious road sometimes to getting the coverage you need.
If you are an individual receiving Medicaid benefits there are various rights that you are entitled to. For example, if your are denied services for any reason, you are entitled to appeal the decision. The appeal is supposed to be addressed within 90 days from the time it is filed.
Since Medicaid is a program which is jointly funded by state and federal funds, there are definite rules that govern appeals and decisions. In Georgia, where many lawsuits have been filed – especially by and on behalf of individuals with disabilities who have been denied the right to a timely appeal.
Some lawsuits which have been filed against the officials of the Department of Community Health allege that Medicaid has been violating both state and federal law by delaying hearings for people with disabilities who have appealed decisions about their care. The lawsuit states that hundreds of Georgians – many of them disabled – have been subjected to extremely long waits that are illegal trying to get hearings for their appeals of medical services that they have been denied.
The most unfortunate part of this situation is that while there are “backlogs” and delays, individuals are not receiving the care that they desperately need, so in many cases, their health declines, eventually costing Medicaid more money.
Some examples of this situation are:
• An individual who is a paraplegic with other health issues needs 4 more hours per day of home health care or she will have to return to a nursing home which would cost many times the expense of extra home care. Medicare declined her latest request in January and she appealed in February. Her appeal has still not been heard and it is nearly August. Her case has not even been sent to the office that hears appeals.
• A second plaintiff in an individual with Multiple Sclerosis who has been living in a nursing home. He would like to be in his own apartment because it is a better environment for him and a much better environment for his children. Living in an apartment and receiving home health care would be far more cost efficient than the nursing home. He has been waiting since early March for a hearing regarding his appeal.
These are just two cases in a sea of backlogged appeals. While individuals suffer delay after delay, Medicaid continues to spend more money on services that are not necessarily appropriate or cost effective for too many people in the system. The decisions in these and other cases will hopefully set a precedent and turn the process around so that it is efficient, effective and helpful for those who are depending on it to help them enhance their lives.
Long term care has long been an important issue that needs to be addressed and has been debated many times. With Medicare and Medicaid systems under so much financial strain and with proposals in the works for revisions and provisions, it seems that Congress on both sides of the aisles is grappling with the issue of Long Term Care funding.
This is a serious issue, as it affects millions of individuals and their families and over 10 million individuals who are living at home and receiving services in there homes and in the community. These people need assistance and services and are normally on a very limited income, being cared for by family and friends. They are often in situations where they are trying to stay at home and in the community in which they live, receiving their supports there, rather than ending up in an assisted living or long term care facility.
It has been shown that when a person can stay in the community and in familiar surroundings receiving long-term supports that is the best situation for them if their situation and condition permits. Congress – and other organizations – is looking further into the cost savings and health effects of helping people stay in the community vs. a healthcare facility. There are various studies that have taken place and are taking place – especially in the recent past and currently – trying to determine to continue to fund the essential service of long term care.
With Congress presently looking at ways to buy time so that Bush Medicare cuts - which affect Medicaid drastically – won’t take place immediately, there is a good chance to work on long term care issues at the same time.
In the meantime, if you are dealing with long term care issues, be sure to keep current with what is happening. For current information you can log into www.CMS.gov.
There are stories about individuals and families having some issues with services through Medicaid because of misunderstandings with providers or not understanding their coverage. Sometimes mistakes are made and must be fixed. The majority of the time providers try to work with Medicaid recipients to provide the best service they can.
In New Jersey, however, there is a company that has been in the news lately for doing just the opposite. This story has been touched on before, but there are more details continuing to come out.
The company, Assisted Living Concepts, based in Wisconsin has a large number of assisted living facilities. As in any business, some things work well and turn out right and some things sometimes do not. There are many excellent assisted living companies throughout the country who work hard every day to balance their budgets, help the residents – whether on Medicaid or not – and deal with issues – especially financial ones – that come up.
Unfortunately, at least in this case, Assisted Living Concepts has handled a situation with eight of its facilities in South Jersey in a harmful and totally inequitable way. In these particular facilities, Assisted Living Concepts had a number of individuals staying there and receiving service who were paying for their services out of their life savings. The individuals say that they were told that if their savings ran out, they would be switched to Medicaid and could stay where they were in Assisted Living Concepts facilities.
Instead, when their savings were totally gone – because they had been paid to Assisted Living Concepts for their care – they were told that they had to leave. A complaint was made and a few weeks ago the Public Advocate began an attempt to review records to see how many more individuals were – or had been – in this position with Assisted Living Concepts.
The case has gone to Superior Court, and a judge will decide on whether the records will be released for review. The case is difficult because, though all Assisted Living facilities are supposed to keep 10% of their beds for Medicaid recipients (in New Jersey), some are exempted. The lawsuit being brought by these eight evicted residents has to do with the promises that were made to them that after they used their funds – in one case over $300,000 - they would be able to stay and be switched to Medicaid. These promises were broken, and it is not known how many other promises to other individuals were handled the same way.
It is important to get to the bottom of this so that individuals who are most vulnerable are not taken advantage of in this (or other) ways, but are protected by the system and by the individuals and organizations who are supposed to serve them.
We have heard about the Medicare and Medicaid issues, including inequities and disparities throughout the country. One of the biggest disparities is between Los Angeles and surrounding areas in California and the rest of the country, particularly New York.
New York just got some great news – its new resource level for Medicaid applicants has been raised from $4,350 to $13,050 for individuals and from $6,400 to $19,200 for households of two. Medicare applicants and recipients now have more flexibility in terms of eligibility and access of care. The new legislation is retroactive to April, 2008, and is based on a New York Social Services Law through the 2008 Budget Bill. Previously, people who had to cash in insurance and burial policies in order to qualify for services can now qualify for benefits and keep the assets they will need in the event that they pass away, such as the burial policies. This is not only good business, it is a fair, dignified and equitable way treat people who are vulnerable and need services the most.
Aside from financial fairness, there is the emotional peace of mind that comes along with the new levels.
Now, let’s head to the opposite coast. In the South Los Angeles area, ever since Martin Luther King – Harbor Hospital – closed last summer, there are so many patients in need of care that they start lining up in front of the clinic between 6:00 and 6:30 A.M. each day. The clinic doesn’t open until 8:30 A.M. The number of patients has risen 70% since the hospital closed last year and only a hand full of clinics have replaced the hospital, which was once considered the jewel of hospitals for South Los Angeles.
King-Harbor Hospital was the 17th acute care facility to close in or around South Los Angeles in the recent past, leaving some of the most vulnerable, low-income, uninsured with few choices for care. It has been hard to attract doctors to the area and in an emergency, ambulances often take patients to three or four hospitals before they can get them into an emergency room.
Why the inequities? After all, there are poor and vulnerable individuals throughout the country, and New York is no exception. This is not speculation; it is simply a statement about the facts. In a country that is basically the richest in the world, there might be difference in care and benefits in various states or region for a number of reasons, but the extremes that can be seen in just these two cities are not just slight differences. They are major differences from one end of the scale to the other.
It is time to look at the entire picture and truly try to come up with some solutions for helping the most vulnerable individuals no matter where they live.
Many states do a poor job of regulating Medicaid fraud because it is a not a simple matter economically. After all, for ever dollar Medicaid brings into a state, there is a federal matching dollar hat the state receives. Some states even overpay Medicaid providers, collect matching federal funds, and collect kickbacks of overpayments, thus becoming part of the fraud problem.
The question then becomes, what is the sense behind turning the oversight of Medicaid over to the same government that is participating in the fraud? Their actions have created long waiting lists, rationing of care and poor delivery of not enough care, again controlled by the government.
There is another side to the issue, however. What happens when you need to make the numbers work? It’s important to look at the major problem. There are many honest and caring physicians who try to help as many individuals on Medicaid as possible. The problem is that even the busiest physicians that take Medicare can’t take more than about 28% of their caseload in Medicaid patients, they can’t afford to stay in business because the amount they are reimbursed is lower than the services provided. Therefore, if there are too many Medicaid patients seeing a particular doctor, he loses money until he can’t afford to stay in business any more.
We haven’t even talked about the number of children covered by Medicaid for various reasons. There are over 25 million kids that have various forms of Medicaid coverage. There are Targeted Case Workers and Case Management through Medicaid Rehabilitative Services who do all they can to deal with children’s’ physical and mental disabilities – getting help and services for them while keeping expenses to Medicaid and to physicians under control. A federal-state partnership that exists now to cover these expenses could be eliminated if some politicians get their way.
Looking at both sides, the hope is that the politicians will be able to work with the expenses while remembering that these issues are not only about finances, but at the heart of the issues are children and adults with vulnerabilities and disabilities that depend on the Medicaid system to help keep them well.
