Saturday, October 31, 2009
Hawaii's "sacrifice" of its children becomes a national scandal that extends to the state's elderly and disabled
Hawaii's Governor Lingle's solution to balancing the state budget by cutting the school year by 17 Fridays has now attained the level of a national scandal. An editorial in today's New York Times notes that "Hawaii has sacrificed its own schoolchildren" who are now "learning a terrible lesson in how little their government and teachers think an education is worth." A week ago, US Secretary of Education Arne Duncan wrote in an opinion piece published in the Honolulu Advertiser that Lingle's "furlough Friday" plan was "inconceivable" and went on to note that Hawaii had already received $105 million in stimulus funds for education, and is scheduled to receive a total of more than $500 million for education. Today's NYT editorial notes that Hawaii "instead used the $105 million to cut its own contribution to education, which was legal but hardly admirable." I've been asking since June what Hawaii is doing with it's additional stimulus millions received for Medicaid. As of October 23, Hawaii has received $154 million that can't be spent on anything except Medicaid. The federal requirements for receiving Medicaid funds stipulated the money couldn't be put into any reserve or rainy day account. Hawaii's state medicaid director admitted the state used part of the money to pay back bills and put the rest into the general fund, but that was about $80 million ago. Every parent, caregiver and service provider in Hawaii that has any contact at all with the state's 'aged, blind and disabled' population can tell you that while these millions of tax-payer gift funds flowed into the state's bank accounts, Hawaii has been cutting Medicaid services by as much as 88%. These budget cuts are specifically targeted at the home and community-based services that enable our elderly, as well as adults and children with special health care needs, to remain at home with their loved ones. The cuts are being implemented by the two for-profit insurance companies that took over care of Hawaii's "aged, blind and disabled" population on February 1. We have the evidence to show that those two for-profit insurance companies are cutting services by means of constantly altering the scoring tools they use to qualify people for home services. A federal judge just stopped California from implementing Medicaid home services cuts because the scoring tools were being abused to the point of violating the Americans with Disabilities Act and civil rights granted under the Olmstead Decision. Meanwhile, we've just realized that Hawaii's Department of Education may be in violation of federal Medicaid law as well. The reverse opt-out letter the department sent to parents in December 2008 does not appear to meet federal requirements for Medicaid billing. I asked my daughter's school system for an itemized accounting of what they had billed Medicaid on her behalf over the past year on Monday, October 19. I asked to receive it by Friday, October 23. As of today, I still don't have it. What's the hang-up? If records were being maintained the way federal Medicaid law requires, then it should have been a relatively simple matter of sort and print. In February of this year, the Hawaii state auditor's office "revealed an organizational culture of disregard for ...procurement laws and rules" in the DOE's procurement office. The report noted "that culture has allowed office directors, managers, and staff to believe they have the discretion to unilaterally determine whether compliance ... is in the best interest of the department." As the parent of a child with disabilities, my experience has shown that same culture of disregard for the law extends to most of the contacts I've had with employees of the Department of Education, Department of Health and Department of Human Services. I filed complaints against Hawaii with the DHHS Office for Civil Rights and the federal agency that regulates state Medicaid programs and spending (CMS) in July and August. I know that CMS has had extensive conversations with state employees, but illegal service cuts affecting children with disabilities were happening as recently as yesterday. Hawaii isn't just sacrificing it's schoolchildren, it's condemning its entire population of children and adults with special health care needs. Children's lives are, literally, being balanced against company profits while state and federal officials turn a blind eye. If federal officials like the Secretary of Education can't get the state to behave legally, who will? If the federal office that regulates Medicaid can't get the state to behave legally, who will? When regulation fails, how long before enforcement steps in? Do we really have to wait for a child to die?
Thursday, October 29, 2009
What is Case Management Here's how the federal regulators of Medicaid recently (June 30, 2009) described case management services for an individual with disabilities:
we recognize the advantages of a team approach to case management services. For example, a lead case manager could coordinate resources and expertise from providers of medical, education, social, or other services for the benefit of the individual in developing a comprehensive plan of care and facilitating access to services. To facilitate this service model, States may set differential rates to reflect case or task complexity that would ensure sufficient payment to reflect the costs that case managers may incur in consulting with other practitioners.For the parents and caregivers of people with special health care needs, dealing with all the different local, state and federal bureaucrats can be "the death of a thousand cuts." This definition entitles the people we're caring for to an individual (or maybe two) whose job it is to coordinate with all the different government departments -- Medicaid, EPSDT, Department of Education, Department of Health, Department of Human Services, Vocational Rehab -- plus the individual's doctors, therapists and service providers. Who is entitled to case management under Medicaid? Case management is a federally required minimum service to be offered by every state's Medicaid program for children under the age of 21 (EPSDT) (42 U.S.C. 1397jj). Case management is also required for adults and children with special health care needs who are participants in a Medicaid waiver program authorized under Section 1915(b) or 1915(c) of the Social Security Act (see 1915(c)(4)(B) and 1915(b)(1). In Hawaii, this would cover everyone who is still enrolled in the state's DDMR waiver program. And at least in the state of Hawaii, case management is a requirement for all 37,000 aged, blind and disabled individuals who are participants in the state's new Section 1115 QExA managed care program (see Chaper VI, section 28(c)(ii) of the document authorizing the creation of the QExA program). How to obtain case management services A 2004 government pamphlet aimed at explaining to parents how to use EPSDT includes instructions on how to obtain medically necessary items and services directly from your Medicaid provider. The process of obtaining individualized case management services should be as simple as giving your Medicaid provider a letter of medical necessity written by a physician or other appropriate medical or educational professional, and a doctor's prescription for the services. If you live in a state that adheres to federal Medicaid law, that should be it. If you live in a state that does not adhere to federal Medicaid law, or worse, has for-profit insurance companies interpreting federal laws, the process can be full of stress, frustration and never-ending delays. Case Management and your child's IEP Federal law requires "Medicaid to be primary to the Department of Education for payment of the health-related services provided under IDEA." More recently, the federal office that regulates Medicaid published the following in the Federal Register on June 30 2009:
Medicaid reimbursement remains available for targeted case management services and other covered services, which are included in an eligible child’s Individualized Education Program (IEP) or Individualized Family Service Plan, consistent with section 1903(c) of the [Social Security] Act.A handbook published by CMS in May 2003, and re-ratified by the June 30 ruling, includes a list of services that are the responsibility of the case manager of a child under the age of 21. Some of these include:
A parent or caregiver can apply to their Medicaid provider directly for a case manager, and expect all these services to be provided for their child. These services could also be provided by the school, which will then bill Medicaid for the services, and for the administrative time spent arranging for them. In 1979, Jimmy Carter formed the first federal Department of Education. In the 14 months between then and the change of Administration in January 1981, the DOE published a blueprint for how schools and Medicaid should work together for the benefit of the student.
- Making referrals for and/or coordinating medical or physical examinations and necessary medical/dental/mental health evaluations.
- Making referrals for and/or scheduling EPSDT screens, interperiodic screens, and appropriate immunization, but NOT to include the state-mandated health services.
- Referring students for necessary medical health, mental health, or substance abuse services covered by Medicaid.
- Arranging for any Medicaid covered medical/dental/mental health diagnostic or treatment services that may be required as the result of a specifically identified medical/dental/mental health condition.
- Gathering any information that may be required in advance of medical/dental/mental health referrals.
- Participating in a meeting/discussion to coordinate or review a student’s needs for health-related services covered by Medicaid.
- Providing follow-up contact to ensure that a child has received the prescribed medical/dental/mental health services covered by Medicaid.
- Coordinating the delivery of community based medical/dental/mental health services for a child with special/severe health care needs.
- Coordinating the completion of the prescribed services, termination of services, and the referral of the child to other Medicaid service providers as may be required to provide continuity of care.
Coordination of all services -- outreach activities, screening programs, treatment, and follow-up services -- should be emphasized between school health and other health care providers, and social agencies in the community, to avoid duplicating efforts, increasing costs of services and adding further stress to the child and family. A means by which one care plan, if at all possible, can be used as a principle vehicle for monitoring the provision of services is a priority area for action... Schools should develop a plan ...[to] determine the extent to which health services are being provided, and the degree to which coordination of services between EPSDT and other programs is taking place.For any child on Medicaid, the IEP should be a single document that incorporates all the services a child receives, whether from DOE, Medicaid, a Medicaid managed care company, or private organizations. And that IEP needs to include the case manager who will coordinate all the services being received. Who can NOT be the case manager? Federal law [42 CFR section 441.18(a)(6)] prohibits "providers of case management services from exercising the agency’s authority to authorize or deny the provision of other services under the plan." This means that the people at Medicaid who authorize and deny Medicaid services cannot also provide case management services. In Hawaii, for instance, UnitedHealth Group and WellCare Health Plans, which authorize and deny services for their Medicaid participants, cannot also provide the case management services for these participants. It would be a conflict of interest.
Sunday, October 25, 2009
Children's Disability Rights Education Association President Summer Harrison and Vice President Linda Nuland-Ames on Thursday called for a full state audit of Medicaid spending by the Hawaii Department of Education. Harrison and Nuland-Ames were at the annual Kauai DD Committee Legislative Forum, presenting the results of their past several months of research into Hawaii's Medicaid programs. The subject of the DOE furlough Fridays, the first of which was due to happen the next day, came up. Harrison pointed out that DOE services that were paid for by Medicaid could still take place on Fridays. Harrison had established that her daughter's paraprofessional service through Nursefinders was likely a Medicaid financed service since it was to continue on the furlough Fridays. Nuland-Ames asked how many parents at the meeting knew that DOE could bill Medicaid directly on behalf of their children. No one was. A few years ago, Medicaid told inquisitive parents that it wasn't any of their business, Nuland-Ames noted. Within the past week, Harrison had contacted her daughter's school to demand an accounting of all services and items billed to Medicaid by DOE on Hannah's behalf. She asked for the accounting by Friday, October 23. Her district office emailed to say she would be hearing from someone, but as of the writing of this post, still hasn't responded. Some but not all parents remembered the letter they had received from DOE in December 2008 stating that failure to return the letter would be permission for DOE to bill Medicaid on their children's behalf. According to research done by CDREA and published on their website, it would appear that the Hawaii DOE letter meets none of the federal requirements for parental notification of and permission for DOE billing of Medicaid on their child's behalf. Harrison reminded the state legislators in attendance of the Hawaii auditor's report on DOE's procurement office, published in February 2009. The auditor's office
revealed an organizational culture of disregard for procurement rules in the Office of School Facilities and Support Services (formerly known as the Office of Business Services and referred to herein as the “Office of School Facilities”). That culture has allowed office directors, managers, and staff to believe they have the discretion to unilaterally determine whether compliance with procurement laws and rules is in the best interest of the department.She pointed out that while she didn't know if any Medicaid billing went through the procurement office, or if that was done someplace else in DOE, the fact that the schools couldn't give a parent an accounting within five days raised concerns. Given the current economy, the public furor over furlough Fridays which are intended to help the governor balance the state budget, and the issues raised about Hawaii's two for-profit Medicaid companies, CDREA's request for a state audit of DOE use of Medicaid funding was met favorably.
Saturday, October 24, 2009
CDREA presents results of its fact-finding investigation into Hawaii's Medicaid Managed Care program
On Thursday, the Children's Disability Rights Education Association presented the results of its investigation into Hawaii's Managed Care Medicaid system at the annual Kauai DD Committee Legislative Forum. Here are some of the highlights of that presentation. Background On February 1, 2009, about 37,000 people on Medicaid in Hawaii lost their right to freedom of choice in their medical care, as their Medicaid care changed from a "fee for service" plan to an HMO, known as a Managed Care Organization or MCO. Two for-profit, out of state companies were awarded the contracts: UnitedHealth Group operating under the name of Evercare, and WellCare under the name of Ohana. UnitedHealth is headquartered in Minnesota, and WellCare in Florida (Ohana is a subsidiary of WellCare of Arizona which is itself a subsidiary of WellCare Health Group). Economics of the transition *While Hawaii transitioned its Medicaid program to the two out-of-state corporations, the state retained 72 employees who moved from the Department of Health to the Department of Human Services (per the state's March 2009 amended budget). Rather than providing direct services, these employees are now charged with overseeing Evercare and Ohana, so overhead was not reduced. *Hawaii's Medicaid budget, which used to pay for state employees and their benefits in addition to medical payments, now pays for state employees and their benefits, all the administrative costs (salaries and benefits) of each of the two private for-profit companies that have been hired to provide Medicaid, all the administrative costs of the for-profit sub-contractors that both contractors hire to perform specialized services like medication authorizations or travel, the profit margins for each of the contractors and sub-contractors, and, with what's left over, medical payments. * The second quarter of 2009 (April, May, June) represented the first full quarter of UnitedHealth Group taking over its portion of Hawaii Medicaid. This is also the quarter that Texas fired Evercare. The company reported a profit margin for that quarter of 3.97%. *Also for the second quarter of 2009, WellCare posted a profit margin of 2.07%. *If Hawaii's current Medicaid budget was, say, $1.2 billion, and between them, UnitedHealth Group and WellCare are skimming about 3% off the top, that means about $36 million a year is heading straight out of Hawaii to Florida and Minnesota, before anyone goes to work for the day. *If, for instance, Hawaii's portion of the revised Federal matching rate (FMAP) was between 25% and 35%, depending on the program, then about $22 million of that $36 million is coming from Federal funds supplied by American tax payers, and includes Hawaii's stimulus funds. *The transition to Hawaii's two for-profit managed care companies has done wonderful things for the profit margins of both UnitedHealth Group and WellCare but is losing the state millions of dollars worth of jobs and services every month. A little about Evercare and UnitedHealth Group * Evercare was fired by the Texas Health and Human Services Commission on May 31, 2009. After receiving 1300 complaints in Evercare's first year of operation in Texas, the company was fined $630,000 earlier this year and instructed to fix a variety of service delivery and payment problems. According to the Dallas Morning News, it was "with limited success." *UnitedHealth reported its net income for the third quarter of 2009 was 13% higher than it was for the same quarter a year ago, due primarily to the growth of its Medicaid and Medicare contracts. *A December 2007 article in UHG's hometown newspaper reported the insurance megacompany had paid out $18 million just in claims-related penalties to 38 states. *In January 2009, UHG paid out settllements of $350 million to the American Medical Association and another $50 million to the state of New York . *A research company that is wholly owned by UnitedHealth, Lewin Group, is producing statistics that leaders against health reform keep citing as "independent" and "nonpartisan". *UHG paid a settlement of $895 million in a class action suit brought by its own shareholders. A little about WellCare Health Plans *WellCare, which receives 99% of all income from Medicaid and Medicare programs in 18 states, the District of Columbia and Puerto Rico and has no private policy business, reported a whopping 69% increase in its net income for the second quarter of 2009 over the same period of 2008. *In May 2009, WellCare paid the state of Florida $40 million in restitution PLUS $40 million in penalties for defrauding the state's Medicaid program, and particularly their children's Medicaid program. *Also in May 2009, WellCare paid $10 million in civil penalties to the Securities & Exchange Commission *In August 2009, WellCare paid a civil penalty to the Florida Election Commission of $120,000, for "questionable" campaign contributions Conclusions and Questions The purpose of the event on Thursday night had been to give our local disability community an opportunity to let state legislators know the problems we are all having due to the state's cutting of Medicaid services. CDREA President Summer Harrison and Vice President Linda Nuland-Ames asked our legislators the following questions: 1. Why are we allowing two out-of-state for-profit companies to gain their profits at the expense of services for our most vulnerable populations -- the elderly and disabled -- while siphoning off jobs and profits to other states? 2. The percentage of Medicaid paid by Hawaii (as opposed to the federal percentage) went from 45% down to 33%, representing a 27% cut in Hawaii's budget contribution. If Hawaii could get a 27% cut without reducing services by a dime, why has the state continued to cut Medicaid services that benefit the aged and disabled population? 3. As of October, Hawaii has received an additional $151 million in stimulus funds that can only be used for Medicaid. What is it being spent on? State Medicaid Administrator Ken Fink said that part of it was being put into the general fund, but wouldn't that be a violation of the terms of receiving the stimulus funds? 4. Will Hawaii be taking advantage of the $20 billion in Health IT grants recently announced to grow our state's high tech industry? Or are we going to pay it to the 2 out-of-state companies so they can hire more people out of state? CMS also offers free technical advice so that states can develop their Medicaid IT programs, eliminating the need to hire outside for-profit companies to administer the budget. 5. And out of all the companies that could have been chosen to supply Hawaii's Medicaid services, how did these two particular companies get the contract, especially given their less-than-stellar histories? Lawmakers attending agreed that Hawaii's state auditor should be asked to resolve the fate of the state's millions of Medicaid stimulus dollars.
Posted by Disability Mom at 1:54 PM
Tuesday, October 20, 2009
A U.S. District Court judge in California yesterday put a halt to Medicaid cuts in home and community services that were due to go into effect on November 1.
“This is a big day for people with disabilities, their families and seniors throughout the state – their right to stay safely in their homes - and not be forced into nursing homes or other institutions - has been reaffirmed by the Court,” said Paula Pearlman of the Disability Rights Legal Center.These are the same kind of Medicaid service cuts, targeted at the same population group (the elderly and people with disabilities), that have resulted in civil rights legal actions in at least 12 other states. At least three states are under federal scrutiny as to whether states are systemically breaking federal Medicaid law and the ADA. A similar ruling took place in Tennessee earlier this year. On the other hand, a similar case brought in Hawaii was literally stymied by the District Court judge, who refused to give the plaintiffs any opportunity for appeal and left no alternative but withdrawal of the case. Medicaid deals with federal civil rights. As long as the individual states have the ability to "define" their local Medicaid programs as they see fit, with no necessary reference to the law, then there can be no equality for our elderly and medically challenged populations. It's left up to public interest law groups and exhausted parents to fight for federal civil rights on a state by state basis, as no one at the federal level seems to want to guarantee that states follow federal law.
Posted by Disability Mom at 8:38 AM
- Disability Mom
- I'm the mom of a child with disabilities. Hannah's first neurologist said she might never develop beyond the level of a 2 month old infant, and there wasn't anything I could do about it. The brain damage was just too severe. Nine years later, she walks, uses a touchscreen computer and I've just been shown she can learn to construct sentences and do simple math with the right piece of technology. Along the way, I discovered I needed to teach myself what Hannah's rights to services really were. Learning about early intervention services led to reading about IDEA and then to EPSDT. I've been waiting for the Obama administration to realize the power and potential of EPSDT for the medical rights - including the right to stay at home with their families - of children with disabilities. The health reform people talk about long term care, and the disability people talk about education and employment, but nobody is talking about EPSDT. So I am.