Securing Attendant Care for a Young Woman with Traumatic Brain Injury

Xiani’s mother was very distraught when she called PHLP.

Xiani is a 17-year old, non-verbal, young woman living with traumatic brain injury, spastic quadriplegia, and cerebral palsy. She relies on a Home Health Aide to help her meet basic daily needs, including grooming, bathing, and feeding. The aide also accompanies Xiani to school to ensure that her needs are met throughout the day and that she safely gets to and from school. This arrangement was working well.

But Xiani’s Medicaid managed care company (insurer) notified the family that it would no longer pay for Xiani’s aide at school. The mother was understandably distraught. Why would the insurer deny Xiani these essential supports? Her needs had not changed. Without the aide Xiani could not attend school, her high school career would end prematurely, and Xiani’s mother would miss work to stay home and care for her daughter.

Fortunately, Xiani’s mother called PHLP.

PHLP challenged the health insurer’s decision. We worked with Xiani’s mother, her school’s special education program, and the home health agency to develop better documentation about the necessity of these services during the school day. On the eve of the hearing—after PHLP submitted the new information—the insurer overturned its denial!

Xiani’s mother was thrilled her daughter would keep her aide during the school day. She expressed gratitude for our help. It’s frustrating and scary when essential services for medically vulnerable children are threatened. PHLP exists to assist to families like Xiani’s access medical, social, educational, and other services.

Where do you go when the healthcare system fails? For more than 20 years, PHLP has been that place. We stand by people whose physical and mental well-being are compromised by illness. We fight for individuals and families—like Xiani’s—who need essential services and supports.

Each year, we counsel thousands of low-income Pennsylvanians distraught by the decisions of health insurers that reduce or terminate an essential benefit. In our experience, Pennsylvanians challenging insurance denials are more successful when they receive expert guidance. Few are able to fully understand the standards of proof to prevail, especially when high levels of emotional involvement often cloud that understanding.

PHLP knows the rules of the insurance programs and knows how to prove the need for a health care service or treatment. We protect some of the most vulnerable consumers in our managed care system—e.g., medically fragile children like Xiani.

We are appreciative for the fellowship of the many agencies with whom we partner, and we thank every one of our donors because that support has improved the lives of thousands who have turned to PHLP for direct help.

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 November 29th.

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, please consider a gift to PHLP and to Pennsylvania's most vulnerable.

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There is no November Health Law News this month, but please be on the lookout for a combined November-December HLN next month.

What We're Reading

Post-Election Symposium: Health Care Policy in 2017, Alliance for Health Reform, November 16, 2016.

Last week the Alliance for Health Reform hosted a post-election, half-day symposium previewing critical 2017 health care policy issues. Their panelists reviewed what can be learned from the election results and public opinion, what priorities can be expected for the new Trump administration, and what health care issues will be on the agenda for the new Congress.

As Insurers Cut Brokers’ Commissions, Consumers May Have One Less Tool For Enrollment, Julie Appleby, Kaiser Health News, November 1, 2016.

“Some insurers — including Cigna and Aetna — will not pay licensed agents and brokers a commission for helping people enroll in individual health insurance coverage for 2017 in many states, while others have reduced their commissions. They join UnitedHealthcare, which dropped commissions on new business this year in many states.

That is already prompting some brokers to step back from the exchanges when open enrollment begins this week, which could be a hurdle for consumers who normally would seek help from brokers in navigating the complexities of insurance coverage. (Government-supported navigators are still available.)”

Presidential ‘Parity’ Panel Offers Steps To Treat Mental Illness Like Other Disease, Jenny Gold, Kaiser Health News, October 31, 2016

“Since the passage of the Mental Health Parity and Addiction Equity Act in 2008, health insurers and employers have made progress toward improving coverage for mental health and substance abuse issues. Most insurance plans, for example, no longer charge higher copays or separate deductibles for mental health care.

But there have been significant problems with the parity law, too, including lax enforcement and little guidance for the public about the law itself or how to file a complaint. Over the past seven months, the task force received 1,161 public comments from patients, families, insurers, advocates, state regulators and others.”

Nonprofits push to get uninsured covered under Obamacare, Wes Venteicher, TribLive, October 29, 2016.

“Groups such as Pittsburgh-based Consumer Health Coalition and Philadelphia-based Pennsylvania Health Access Network plan to call everyone they can who has enrolled in one of the plans to remind them of their options as they receive letters stating their new rates…

The nonprofits, with about $3 million in federal grants for the fiscal year, will remind people that federal subsidies increase as rates increase, blunting their impact, and that many people can save money by shopping around to find a new plan.”

More PA Kids Have Health Insurance, BCTV.org, October 28, 2016.

“A report released last month by the Georgetown University Center for Children and Families (CCF) showed that between 2013 and 2015, the number of children without health insurance in the state dropped by 36,000, achieving an overall insured rate of almost 96 percent.” CCF’s sixth annual report on children’s health care coverage reveals that Medicaid expansion, the Children’s Health Insurance Program (CHIP) and other provisions of the Affordable Care Act helped significantly lower uninsured rates of children. Yet CCF’s work also reveals that the most of the public does not know of the success.

Helping People in Need Get the Health Care They Deserve.