PHLP eNews: November 2014

Read about the long-awaited ruling regarding coverage of in-school autism care, our 13-year-old client Katie, and Giving Tuesday 2014

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PHLP Helps 13-Year-Old Katie Stay in School with Her Aide

For children with chronic disorders such as cerebral palsy, which affect a person's ability to move and maintain balance and posture, the support of one-on-one aides is critical to remaining safe at school. Katie, a 13-year-old from Luzerne County with cerebral palsy, has relied on an aide during the school day and when riding the bus to and from school. Katie’s aide is paid for by Medicaid, the insurance program created to support children with complex medical conditions.

But recently, Katie’s Medicaid Managed Care Plan (Insurer) notified her family that they would terminate Katie’s helper, even though there was no improvement in Katie’s functioning or change in her personal care needs. Her Insurer simply concluded that these services were no longer necessary and that educational aides in Katie’s classroom should meet her needs.

Fortunately, Katie’s family contacted PHLP.

We advised Katie’s mother to appeal the Insurer’s denial immediately so that Katie could keep her personal care aide until her legal rights were exhausted. Then we gathered support from Katie’s school, her doctors, and her nurses to demonstrate her continued need for personal care assistance. All understood that there is no cure for cerebral palsy and that medically necessary treatment includes the type of in-school support already in place. Presented with testimony and documentation, Katie’s Insurer overturned the denial.

Katie’s mother could not be happier or more relieved now that Katie, with her aide by her side, can safely continue attending school.

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

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Unscrambling Autism Laws: PA Supreme Court Preserves Family's Challenge Requiring Insurers to Pay to Treat Children with Autism

John and Suzanne Burke knew how important it was for their seven-year-old son to receive applied behavioral analysis therapy, which medical professionals say is vital to their son’s social acclimation and development. When Independence Blue Cross (IBC) refused to pay for Anthony’s therapy in school, the Burkes called PHLP.

In a long-awaited ruling, the Pennsylvania Supreme Court held Pennsylvania families like the Burkes have a right to fight in court over whether an insurance company must cover in-school autism care. Experts agree that treatment interventions should be consistently provided both at home (which IBC pays for) and at school (which IBC does not) for greatest effectiveness. Having the insurer pay for services at home and school allows services to be provided by the same agency and staff in both settings to ensure consistency of treatment and to build trust between the child and his treatment staff.

The Burkes were represented by Senior PHLP Attorney David Gates. At issue was a Pennsylvania law called Act 62, the Autism Insurance Law, which requires private health insurers to pay for diagnoses and treatment of autism for children and adolescents. IBC argued that since the therapist worked at school, the law didn’t apply to them. A state trial court decided Independence Blue Cross, like all private insurers, was legally required to pay for needed services and treatment for autism, including those provided in school.

IBC appealed to the Pennsylvania Superior Court which reversed the trial court's decision without addressing the merits. It dismissed the Burkes' complaint for lack of jurisdiction, finding the Burkes did not have the right to have courts decide their appeals against insurance companies that deny their claims.

Writing for a unanimous Supreme Court, Justice Thomas Saylor wrote that the Superior Court should not have tossed the Burkes' case. This is a matter of “public importance,” wrote Justice Saylor, affecting “potentially thousands of individuals across the commonwealth diagnosed with autism spectrum disorders." Families like the Burkes need access to a judicial forum over Act 62 coverage.

Senior PHLP Attorney David Gates was pleased with the Court’s decision.  "The Court has enabled the Burkes to pursue their legal claim against Independence Blue Cross so we can get to a final decision on whether Blue Cross is required under state law to cover their son's autism treatment in school."

After Black Friday and Cyber Monday, Giving Tuesday provides the opportunity to get into the true holiday spirit of giving back to those in need. PHLP celebrates the generosity of its supporters on December 2nd.

PHLP offers its services free of charge, and relies on contributions like yours to provide our services. Your support helps Pennsylvanians access health coverage for themselves and their families, giving them peace of mind and the opportunity to be independent, contributing citizens of our Commonwealth. While you are shopping for gifts for loved ones, consider a gift to PHLP and to Pennsylvania's most vulnerable.

PHLP in the News

Corbett, Wolf Could Be on Medicaid Collision Course, Philadelphia Inquirer, November 11, 2014

Pa. Supreme Court Reinstates In-School Autism Coverage Claim, Legal Intelligencer, November 4, 2014

Thousands of Pennsylvania Women Could Lose Some Health Coverage, Pittsburgh Post-Gazette, October 24, 2014

What We're Reading

California's Managed Care Project for Poor Seniors Faces Backlash, Kaiser Health News, November 19, 2014

Anna Gorman reports that California’s experiment aimed at moving almost 500,000 low-income seniors and people with disabilities automatically into managed care has been rife with problems in its first six months, leading to widespread confusion, frustration and resistance. California's experience is relevant as Pennsylvania considers integrated, managed care for its dual eligible population.

Coverage Of And Commentary On the U.S. Supreme Court's Decision On King V. Burwell

In 2015, the Supreme Court will consider whether tax subsidies are available to individuals who purchase their health insurance on an exchange (marketplace) operated by the federal government. The editorial board of the Philadelphia Inquirer urges Pennsylvania officials to start its own marketplace to head off this legal threat to subsidized care. At Think Progress, Ian Millhiser provides a layperson’s guide to the case, while in his column for The New Republic Jonathan Cohn describes what the Supreme Court could do to insurance premiums.

Transportation Troubles Hinder Care for Health Care Superusers, The Morning Call, November 2, 2014

“When a team of health-care and social service workers in Allentown went looking for frequent visitors to emergency departments and hospitals, they quickly learned that many were dialysis patients. Ask those patients what's most important for maintaining their lives, and they'll, of course, say the dialysis treatment, when a machine cleans the bloodstream the way healthy kidneys would. Next on the list? For many, it's transportation.”

This is one of several articles written by Tim Darragh about low-income patients who have very high health care expenses.

*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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