Tuesday, November 30, 2010

Hawaii Medicaid office takes responsibility for coordinating interdepartmental services, including DOE, for children covered by Medicaid

On November 23, Dr. Kenneth Fink, State Medicaid Director for Hawaii, sent me a letter.  The letter began:

The Department of Human Services/Med-QUEST Division (MQD) is committed to assuring that your daughter, Hannah, has coordination of medically necessary Medicaid services that are being provided through multiple State agencies......To facilitate this, we are requesting your consent to allow the Department of Education (DOE) to release to us a copy of Hannah's most recent Individualized Education Plan (IEP).

I haven't heard whether any of the other hundred-thousand children receiving Medicaid, or even the twenty-thousand some kids in Special Education, have received the same letter.

This letter, while addressed only to my daughter, opens up a tremendous opportunity for all Hawaii's children with special health needs.  The DOE no longer has the final say in the services provided to your child enrolled in Medicaid.  The state Medicaid office is essentially assuming responsibility for ensuring your child's medically necessary services are provided, if not through the school, then through either Evercare or Ohana.

For instance, if your child's doctor prescribes five hours a week of occupational therapy and the school is only willing to provide two, you can count on Medicaid to handle providing the other three.

It inadvertently brings up the related question of why Hawaii DOE doesn't appear to be actively enrolling kids in special ed into Medicaid.  Once they do, the federal Medicaid budget (administered out of Dr. Fink's division) picks up 75% of the cost of all that kids' services that are provided by the school.  The budget savings that could be realized by transferring that 75% from state coffers to federal ones are enormous, and why it's being ignored by our local school district is beyond my comprehension.

Whether that issue is related to the fact that Evercare and Ohana are becoming aware of  requirements that EPSDT funds be paid out of the capitation fees they receive, I can't say.  Paying for school therapy services could dig into the $15 million profit they make off the monthly $100 million or so in capitation fees Hawaii pays them.

For parents and advocates, MQD admitting this responsibility for service coordination opens an alternative for receiving services DOE either can't or won't provide.  Federal Medicaid EPSDT regulations and laws provide more protection and additional means for winning disputes than can happen with IDEA alone.

Monday, November 29, 2010

Was threatening letter from Evercare retaliation for blog stories?

The last time I posted on here was November 4.  I wrote two articles that day, one of them on how UnitedHealth Group in Hawaii had been under a "Corrective Action Plan" since April for violating grievance and appeals rights.

On November 6, I received a threatening letter from David Heywood, Executive Director of UnitedHealth's Evercare for Hawaii.   The letter had been sent out by certified mail on November 5.

They wanted me to stop emailing federal officials, and to push all the care services I've been fighting for since September 2009 under the rug.  Let's just start over again from scratch.

Here is the letter from Heywood.
110510 Cert Letter f Heywood                                                            

Here is the email I sent him in response on November 21.
My Email to Evercare Re Hannah                                                            

Thursday, November 4, 2010

Hawaii Medicaid, UnitedHealth, and the Election

With the elections over, some interesting coincidences have arisen involving unregulated donations to Republicans successfully running against Democratic incumbents,  and states that have turned over parts or all of their publicly funded programs (i.e., Medicaid and Medicare) to profit-making corporations such as UnitedHealth and Wellcare.

On November 3, Public Citizen published a report of the congressional races where unregulated third-party contributions played a role.  They found that in 58 of the 74 congressional elections where power changed hands, outside spending from unregulated sources ranged as high as $8.7 million for the new Republican senator from Illinois.

The report reminded me of something I read earlier this summer.  On July 26, The Center for Public Integrity reported that the five top profit making insurance companies were talking about forming a non-profit.  The purpose was to funnel about $20 million towards candidates who would protect their interests when the time comes to write the actual regulations for health care reform.  According to the article, one of the new association's biggest targets was going to be health reform's insistence that the companies actually spend eighty percent of the premiums collected on medical care and services.
Insurers are concerned about the new regulations because the new law mandates consumer refunds if the companies’ administrative costs are excessive.

Health Care for America Now, a coalition of consumer groups that backs the new law, last week issued a study which indicated that if the six biggest for-profit insurers were required to meet the new legal standards in 2009, they would have been obligated to pay a total refund of $1.9 billion.
CPI identifies 71 candidates in 34 states where winning Republicans who received unregulated campaign contributions overturned incumbent Democrats.

Coincidentally, Medicaid and/or Medicare services in 33 of those states are administered by for profit health companies.  UnitedHealth alone operates Medicaid or Medicare programs in 31 of the 34 states.  The other two companies are Wellcare and Wellpoint.

Thirty of the 71 candidates were concentrated in the ten states (of 34 total) where both UnitedHealth and Wellcare operate Medicaid and Medicare programs.  These are the same two companies that have been in charge of Hawaii's Medicaid programs since February 2009.

Twenty-nine of them were in eleven states where federal Medicaid, DOJ or Civil Rights authorities have intervened since February 2009 to prevent civil rights violations stemming from Medicaid budget cuts.

UnitedHealth operates a Medicaid or Medicare program in thirteen of the total of fifteen states where federal regulators have intervened to stop civil rights violations against people with disabilities.

Hawaii's Medicaid debacle could be a view into the future if for-profit health insurance companies are allowed to continue taking over Medicaid and Medicare.

In the first year after UnitedHealth and Wellcare took over the state's $1.2 billion annual Medicaid budget to help the elderly and people with disabilities stay in their homes, the death rate in that group rose 36%.

UnitedHealth and Wellcare report fairly consistently to the SEC that their Medical Benefits Ratio (the percent spent on actual services out of the monthly premium) is in the 80-85% range.  With Hawaii's annual budget ranging from $1.2 billion to $1.3 billion, that means the two companies are whisking somewhere between $15 million and $25 million a month away to their out of state corporate headquarters.

That's why services are being cut.  Not because the state is running out of money, or the economy is terrible.  But because profit-making health insurance companies have to keep their profit lines going just like the banks do, regardless of the human cost.

Ironically, UnitedHealth has just released a study trying to prove the US will save $3.5 trillion in the next twenty-five years if only every state would turn it's Medicaid and Medicare programs over to them (or companies like them).  What they don't tell you is that is after they take their fifteen-twenty percent cut off the top of what they project will be a $63 trillion business over the next 25 years.

Do the math.  Does the country save more money by turning Medicaid over to these profit-making companies or by using the almost $10 trillion they'd take in profit to restore services to our elderly and disabled citizens, along with all the jobs that sector creates.

UnitedHealth's Hawaii operation under monitored "Corrective Action Plan" since April 2010

UnitedHealth Group's Hawaii operation has been under a DHS-imposed and monitored "Corrective Action Plan" (CAP) since April 2010.  The following was contained in an email I received from CMS on October 20, responding to a complaint I had filed earlier.
CMS and DHS reviewed your September 9, 2010 complaint about Evercare and the lack of oversight by DHS‐Med‐Quest (MQD) Division. You have reported that Evercare is out of compliance with CFR 438, subpart F: Sec 438.400.438.410 in meeting the needs of your daughter, Hannah Harrison. In reviewing your complaint the Med‐QUEST Division (MQD) found that Evercare is out of compliance with some of the required timeframes for both Notice of Adverse Action (NOA) and processing of appeals. MQD identified on April 5, 2010 that Evercare was not consistently compliant with both timeframe and required information for NOA as well as grievance and appeal regulations. MQD placed Evercare under a Corrective Action Plan (CAP) in April 2010 to assure they are meeting the required timeframes. CMS has assurance that MDQ continues to monitor Evercare in its CAP to assure they are meeting the required timeframes.
Apparently, at some point in time prior to April, federal Medicaid regulators and Hawaii DHS agreed that Evercare (UnitedHealth) had violated my daughter's legal rights.

The obvious question is how many of the other twenty thousand or so medically needy people enrolled under Evercare also had their rights violated? 

And why haven't any of us been notified officially?

In a related issue, CMS told me on May 24 that MedQuest told them Evercare had not denied any services for Hannah, and there were no outstanding complaints.  

All I could do was respond that I had a record of 33 complaint emails I had sent to Evercare over denied services and sixteen emails directly to Patti Bazin.  One of the biggest outstanding issues, I said in my email to CMS, was Evercare's refusal to follow medical recommendations for how to teach Hannah to talk with us using assistive technology.

I didn't have a chance to respond to the October 20 news that Medquest once again was telling federal regulators there were no outstanding complaints for Hannah until November 1. I reported to CMS that it appeared the reports they were receiving from DHS regarding Evercare's adherence to the specified timeframes could be in error.  I had emailed Patti Bazin on June 30 that Evercare had never responded to prescriptions received for medically necessary services received on May 21.  Emails I received from Bazin as recently as October 12 consistently ignored Evercare's failure to approve therapy that would teach my daughter how to talk.

The public deserves to know about this so-called Corrective Action Plan.  The elderly and disabled adults as well as children who have had their rights violated deserve to know.  If the state manages to keep losing my complaints, knowing I blog about it, who else's complaints have disappeared?

About Me

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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.