Client Story: PHLP Secures Home and Community Based Services for Severely Injured Gunshot Victim 

After a gunshot wound left Delaware County resident “Omar” quadriplegic and dependent on a ventilator, his family knew he would require specialized care and had to figure out how to pay for it.  PHLP exists to help families through such crises.
 
The hospital in Philadelphia where Omar was treated wanted to send him to a nursing home, but his family wanted him at home. Because Omar was ventilator-dependent, he required in-home nursing, which would be covered by the Independence Waiver (a Home and Community Based Services waiver program) for persons who meet income and disability requirements.

Despite being eligible for the waiver, Omar was denied! An error in the hospital’s paperwork created a complex chain reaction:  Omar’s financial eligibility information was sent to the Philadelphia County Assistance Office (CAO), which turned him down, giving the mistaken explanation that he lived in Montgomery County (the location of the nursing home in the referral)!

Recognizing that an appeal to the CAO would be a lengthy process, PHLP immediately contacted the Pennsylvania Office of Long-Term Living, which worked with PHLP to get Omar’s financial eligibility information to the right place and obtain a service coordinator to develop a plan for his care. With PHLP’s help, Omar was approved for 16 hours of in-home nursing a day. PHLP also worked with his health insurer to get Omar a power wheelchair, and is currently working to get the cost of a ramp reimbursed so he can enter and exit his home.

Because of PHLP’s intervention, Omar will be home with his family for the holidays, receiving the care and support he needs.

PHLP Advances Emergency Medications Process for Adults on Medical Assistance

An emergency supply process is now available for Medical Assistance (MA) recipients who have reached their limit of six prescriptions per month. Most adults on MA are limited to coverage of six prescription drugs per month, resulting in delays in receiving medically necessary prescription drugs that can put MA beneficiaries at risk. PHLP recognized the danger of the prescription limit and drafted a pharmacy bulletin that will help guarantee the safety of MA recipients. Now, if a drug is denied at the pharmacy because of the six prescription limit, MA recipients can ask the pharmacist for an emergency supply of medication so they have access to their medication while their doctor seeks approval from their insurance. The full bulletin can be found here.

PHLP Advocacy Results in Restored Coverage for Medical Assistance

Typically PHLP’s Helpline serves individual Pennsylvanians who need help accessing health care coverage or services through the public health system. However, PHLP also advocates for health care consumers beyond the case-by-case level. Recently, we received many calls from individuals on Medical Assistance for Workers with Disabilities (MAWD) receiving premium statements that inaccurately showed they were behind on premiums even though they made timely payments. An even more serious error occurred when local County Assistance Offices (CAOs) sent termination notices for failure to pay MAWD premiums when, in fact, the individual was current with their payments!

PHLP brought this to the attention of the Department of Public Welfare (DPW), and at the end of October, DPW issued a Policy Clarification to notify CAOs about the backlog in processing payments.  The CAOs were instructed to review MAWD cases that have been closed for non-payment of premiums and to re-open cases if the system showed only September’s premium as unpaid. Many individuals again have access to the care they need. 

Happy Holidays from PHLP!

As the end of 2013 nears, PHLP thanks everyone whose support helped us secure health care for low-income persons and those who are otherwise vulnerable or disenfranchised.

At the heart of PHLP are the 1.4 million Pennsylvanians who live without health coverage, and the 2 million low-income Pennsylvanians in the Medicaid program. Their experiences and health care needs keep us grounded. We strive to help in every way we can. We’ve obtained health coverage for the uninsured, restored skilled nursing care for developmentally disabled children and adults, and advised low-income seniors confused about Medicare enrollment. The services we obtain for our clients are important to their well being, and provide peace of mind: the kind of peace we wish for anyone who needs medical care. It is a privilege to do this work.

Please consider us when you are making any year-end contributions to charitable organizations and help us continue to advocate for the most vulnerable Pennsylvanians. Your support makes our work possible. Donations can be made by mail or by using our secure online form at www.phlp.org.

PHLP wishes you and your family a happy holiday season and good health in the New Year!