Stopping the privatization of Medicaid and Medicare: Create jobs not profits

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This country is in desperate need of legislation to halt the privatization of Medicaid and Medicare.

It is already costing taxpayers $11 billion a month in a subsidy or bailout or whatever you want to call it, that no one has voted on, and is the driving force behind a civil rights war going on right beneath our noses.

Throughout American history, every minority has won its equality through speaking up on is own behalf. The reason nobody knows about this particular civil rights war, is this time the minority cannot speak for itself.

They are our medically vulnerable of any age, those who because of time or disability would be living in institutions if not for Medicaid. Eighty-six percent of the national Medicaid budget is allocated for their care, to pay for the treatments and services to keep our loved ones at home with their families, or in the communities of their choice.

It may be budgeted for their care, but if it's paid to one of ten major for-profit HMOs, anywhere between twenty and fifty (or more) percent is taken out as a sort of middleman fee.

For our families, these cuts translate into reductions of sterile medical equipment, denials of anything from diapers to wheelchairs to communications devices, and reductions in those very services we need in order to keep our loved ones out of institutions. We sacrifice sleep, jobs, friends and the ability to multitask to try to compensate for cuts that were made to raise company profits.

Legislation imposing a 95% health benefits ratio (the percentage of the per person per month premium the HMO receives that is spent on actual health benefits) will do no good. The Administration effectively acknowledged the power of the criminal culture grown up around these HMOs when they gave Wellcare a "get out of jail free" card in April. No expenses they report themselves could ever be trusted.

The best legislation may be to outlaw capitation payments. Go back to a simple fee-for-service program; after all, it worked fine for forty years. All the county and state workers who lost their jobs when the HMO took over can be hired back. These are the people who are best capable of managing the care of someone who is medically vulnerable anyway, not employees of a for-profit HMO.

If the state goes back to writing the checks (more jobs), we eliminate the profit motive, while pumping $11 billion a month into local communities. That could translate into between 400,000 and 1 million jobs across the country. Every time a nurse is hired, a child or grandparent with disabilities is given forty hours a week of home nursing services, something that literally can mean the difference between life and death.

That could also be seen as a million jobs across the country that have been sacrificed in the past three years to keep profits up.

On my other website, I started a survey in January looking for information on how well states were adhering to federal Medicaid regulations. Not adhering means violating, right? While the sample remains small, every state represented so far is violating one federal regulation or another.

Yet the Supreme Court will soon be considering whether anyone signing up for Medicaid should forfeit the right to "federal Supremacy", turning about 50 million people immediately into second class citizens. The White House has also backed a series of proposed Medicaid regulations that implement this anti-regulation of the human and civil rights of our elderly, our adults and our children with disabilities.

Why isn't it child abuse to steal money intended to be spent on keeping children home with their families? Since when can the government abdicate regulatory control over the recipients of federal funds?

Millions like my daughter who have no ability to speak out in support of their own civil rights, are watching control over their life-and-death decisions being sold off to for-profit HMOs.

The first step to stop this insidious destruction of the human rights of the weakest members of our society is to let Congress and the President know that we know what they have been doing without the voters' permission. It is not over-dramatizing to say people have already died, and will continue to do so, until legislation takes the profit out of Medicaid and Medicare.

Please sign our petition here. With the pending Supreme Court decision, and final versions of those proposed new regulations coming up this fall, we need your voice now to help speak up for our children, those who will always be our children and those to whom we were children.

New Administration policy tells states how to auction off local Medicaid programs to for-profit HMOs without violating regulations

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ADAPT, a national grassroots disability advocacy group, announced today its outrage over the Administration's latest attack against the human rights of America's medically vulnerable children, adults and senior citizens.

The policy was outlined in a letter sent to State Medicaid Directors by CMS (the Centers for Medicare & Medicaid Services, the federal regulatory agency for both Medicaid and Medicare) on Friday, August 5.

Reading between the lines, one purpose of the letter is to outline how states can sell off their Medicaid contracts to for-profit HMOs without violating any pesky federal regulations. Specifically, the letter addresses Medicaid issues only as they relate to the infamous "maintenance of effort" (MOE) regulation imposed under the Affordable Care Act.

At one point, the policy instructions are very explicit:

As detailed in our May 20, 2010 State Medicaid Director Letter, there are a variety of mechanisms available to States to rebalance their long-term support systems for persons with disabilities to achieve compliance with the ADA.

One of the points in the May 20 letter was to laud the "service delivery model" of managed care. These are the managed care contracts auctioned off to the growing for-profit HMO industry. The link to CMS' technical manual for running an honest managed care program does not appear to work any longer.

Government revenue for Medicaid and Medicare is already boosting some of these companies 23% higher for the year than the S&P 500. Unitedhealth, for instance, has successfully mislead both the Wall Street Journal and the New York Times into writing that their specular profits are related to performance in their commercial (employer) division.

Over the past three years, Unitedhealth's monthly income from commercial accounts increased by $300,000,000 while their monthly revenue from the government for Medicaid and Medicare increased by $1 billion. Which sector seems more likely to have produced a 313% increase in net earnings?

Last week's Medicaid policy statement is only the latest in a series of events evident of the Obama Administration's extreme pandering to big business HMOs.

Please help us stop this terrible mis-use of public funds.

UnitedHealth under federal scrutiny in Hawaii over possible Medicare scam

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I reported on January 23 that a Kauai family claimed to have been duped by an employee of UnitedHealth into changing to the company's Medicare plan.

By February 8, federal Medicaid regulators from CMS were involved in the investigation.

This is only the latest in a long line of federal formal and informal audits, oversight and investigations plaguing Hawaii's Medicaid program since the fall of 2009.  In addition to CMS, the DHHS Office for Civil Rights, the FBI/DOJ and even the federal Office for Civil Rights of the Department of Education have all been involved.

I could understand why Lingle and Koller kept all this from the public.  They had built here in Hawaii a perfect Republican dream of how Medicaid should function under privatization, and small problems like deaths, let alone violations of federal laws, were just pesky details.

But where does our new Democratic governor stand with all this?  He seemed to promise an end to privatized Medicaid, but now is letting privatized Medicaid draft state legislation.

Meanwhile, life and death decisions continue to be made daily by people motivated more by profit than medical need.  

Governor Abercrombie, respectfully, you need to step in and put a stop to this before anyone else can be hurt.  Only you and the Feds can do that right now.  And you need to come clean with your voters about the state's dirty laundry and what you're going to do to wash it.

Plea sent to CMS for help in getting Hannah's catheters

It has been suggested to me that the continuing failure of Medicaid to provide my little girl with medically necessary catheters could have ramifications for quality of care and/or access to care issues.

I've emailed CMS to ask if they can help get Hannah the equipment prescribed for her last Friday.

It is just too sad a commentary on how easy it is to victimize a child with disabilities who cannot possibly speak up in their own defense.

What a 50% Medicaid payment error rate could mean for Hawaii

On April 7, I emailed CMS asking to confirm a rumor I had heard.  Part of the rumor had to do with a possible 50% error rate on Hawaii's Medicaid program.

UPDATE:  April 20, 2010
I heard today from CMS that they have confirmed that the two for-profit health insurance companies will continue to operate the state's Medicaid program.  This is good news for enrollees who are in the appeals process from denials of services, medications, etc.

She was not able to confirm, however, anything about the rumor of the 50% payment error rate.

What does a 50% Medicaid payment error rate mean?  It can mean that half of all Medicaid claims are paid twice:  once by either Evercare or Ohana through their capitation payments, and the second time by Medicaid's fee for service program.

Here is how it might happen:

1.  ACS, as the fiscal agent for Hawaii's fee-for-service Medicaid program, charges a fee for every claim they submit.

2.  Hawaii receives matching funds from the federal government for ACS's services, just as they do for the state's QExA program operated by Evercare and Ohana.

3.  ACS is billing the state for claims incurred by patients served by Evercare and Ohana.

4.  ACS would then be receiving federal (and state) funds for claims that are the responsibility of Evercare and Ohana and which are included in the calculations for the monthly per person payments (capitation payment) they receive.  Evercare (UnitedHealth) and Ohana (Wellcare) are retaining their full capitation payments, hence the double payments.

What that means for Hawaii is that suddenly our Medicaid budget could be half of what it should be.  For example, since the state's total Medicaid budget for FY2010 is about $1.4 billion, then suddenly the state might have only $700 million to spend.

A national report by CMS published last year found that the payment error rate nationwide for managed care Medicaid organizations was one tenth of one percent.  Nationwide, CMS found a payment error rate of 8.72%.  These figures, which include Hawaii, are for FY2008, before Evercare and Ohana began their Hawaii contracts.

In March, Hawaii Governor Linda Lingle blamed the state's "Cadillac" Medicaid program for 75% of the state's budget deficit by 2014.  As far as I can tell, the only "cadillacs" may be those driven by whoever is pocketing all these double payments.

Feds Probe Civil Rights Violations in Hawaii

This is a story about how four moms and a dad are changing perceptions of the civil rights of children with disabilities.

Late last week it was learned that the Office for Civil Rights of the US Department of Health & Human Services is opening official investigations into complaints that the state of Hawaii is violating the civil rights of people with disabilities.

The complaints were filed by four Hawaii parents of medically fragile children, and the mom of a young quadriplegic man.

The civil rights violations that are being investigated

The violations stem from civil rights granted through a Supreme Court decision in 1999.  What's become known as the Olmstead Decision ruled people with disabilities had a civil right to receive the medical services that enabled them to stay at home, rather than being segregated into institutions.  These services are provided through state Medicaid health care plans.

This latest investigation mounted by the OCR may be the first to recognize that children with disabilities have a second, inalienable right to medically necessary treatments and services that state bureaucrats cannot deny, limit or reduce.

For years, these treatments and services have been denied, limited and reduced by state bureaucrats and the for-profit private insurance companies that are winning state Medicaid and Medicare contracts across the country.

With the recession, bureaucrats and insurance companies have been looking for ways to save money without people noticing.  The families and caregivers for children and adults with disabilities have been an easy target.  Usually they are just too exhausted to complain.  They are also extremely vulnerable to coercion (such as 'don't ask for so many hours of help or we'll throw your kid in an institution').

We (and I'm one of those moms) are a small population, but cuts to the Medicaid home services that enable our children to live at home with us can give a for-profit company or state a big bang for the buck.  Here in Hawaii, for instance, the 5,663 people receiving home nursing and caregiving services through Medicaid cost the state $120.8 million in 2005 (the most recent year I have both sets of figures).  Our kids are expensive to keep at home, but the alternative is locking them away in big cages (safety beds) in institutions.  The higher risk of death in an institution or without proper home care is acceptable, as state employees and insurance company gatekeepers frequently tell us.

We have all been told, in one way or another, that it wasn't cost-effective for the state to pay to protect our children's lives.

The problem is national in scope

Back on June 29, 2009, the Center on Budget and Policy Priorities reported "at least 39 states have made cuts that harm vulnerable residents to help close budget gaps."


In line with OCR's decision to investigate Hawaii's Medicaid cuts as civil rights violations, the similar cuts in all thirty-nine (at least) states may now constitute civil rights violations.


Hawaii is at least the seventh state in the past year where Federal regulators have intervened on behalf of children and adults with disabilities.  The Department of Justice stepped in to a federal courtroom in North Carolina, Kentucky is under investigation by the OCR, and federal Medicaid regulators (CMS, or the Centers for Medicare and Medicaid Services) have intervened in Idaho, Colorado, Alaska, Tennessee and Hawaii.  


Class action and private lawsuits alleging similar civil rights violations are pending, have been filed or have been decided in at least fifteen states in the past year:  Arizona, California, Colorado, Georgia, Hawaii, Idaho, Illinois, Kentucky, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee and Washington.  


Federal judges in only two states, Hawaii and South Carolina, have decided that potential cuts in services didn't matter since no harm had yet been done. The Department of Justice physically intervened in a similar court case in North Carolina, to ensure that potential cuts were put on hold.


Two federal cases in Georgia have decided that state officials and Medicaid contractors cannot over-rule a prescription from the doctor of a disabled child on Medicaid.  They have a potential financial conflict of interest with the medical needs of the child, and are also prohibited by federal Medicaid regulations from providing case management services to kids as well as adults with disabilities.


In a June 30, 2009 filing in the Federal Register, CMS clearly recognized the potential conflict of interest between state Medicaid gatekeepers and the actual needs of individual children and adults with special health care needs.  Six weeks later, CMS gave the state of Idaho written instructions prohibiting the state  and its Medicaid contractors from denying, limiting or reducing treatments and services prescribed for children with disabilities.  They can review them to ensure they are not fraudulent, but not change them otherwise. 

Meanwhile, back in Hawaii

As mentioned earlier, Hawaii is one of two states where federal judges have been completely unsympathetic to the civil rights of people, particularly children, with disabilities.

This blog has been describing parts of the battle families have been waging here in Hawaii over the past year.

Blocked from judicial relief, in July 2009 I filed a complaint with OCR on behalf of my ten year old daughter Hannah.  There was nowhere to go except up.

Since 2002, I've been waging private battles with the state over Hannah receiving the medical care and educational services she's entitled to under federal Medicaid law.  My daughter's brain damage from birth was so severe her head is still only the size of a six month old infant's, but she has had to have her own lawyers since she was three.

Last year I decided to take my fight on my daughter's behalf public, and help other families in similar situations.  The stories are horrendous, but until now very private of the four families I helped file complaints with the OCR over the past six months.

Four of us have children who are medically fragile.  They can't take food by mouth but instead get liquid diets through tubes in their stomachs.  Two need machines to help them breathe.  Three have life-threatening seizures that cannot be controlled and can erupt without a second's notice.  My daughter is the oldest, the youngest is almost four.

Two of us have had the state of Hawaii threaten us with institutionalizing our children if we didn't back down.  Two more received similar threats from the two for-profit insurance companies who hold the contract for Hawaii's Medicaid home and community based services.

Our fifth family is that of a 21 year old who broke his neck in an accident.  His mind is fine, but he can't turn himself over in bed, feed himself, or even go to the bathroom himself.  Medicaid says he should be fine staying home all day alone, just hoping nothing happens that he would need to be moved.

It's fairly mortifying as a parent to be told your child's well-being, and very life, aren't worth, say, any more than $6,000 per month.  To an outsider that may seem like a lot, but children like my daughter require 24/7 skilled line-of-sight nursing in order to remain in their homes.

Without it, Hannah would have to be shut into a giant crib with three foot high walls of metal bars, and a roof to match.  She's too mobile to be left alone, and an institution doesn't have the staff to watch her all the time.

Instead, it costs about $30,000 a month to keep Hannah at home.  Right now, at least two-thirds of that is being paid by the federal government.

That $30,000 goes completely into local job creation.  The ARC of Hawaii estimated back in 2003 that for every $10 million the state cut from it's Medicaid budget, it lost over $21 million in employment, services and taxes.

In 2008, Hawaii paid out about $167.5 million to provide home nursing and care services for medically needy children and adults.  At that time, the state's share was about 45%, or $67 million.

As of mid-January, Hawaii had received about $184 million in federal stimulus funds that could only be spent on Medicaid.  Presumably, about eight percent of that is going straight off the top to the two for-profit insurance companies that have state contracts to provide services to the medically needy community.

One of those two companies is UnitedHealth Group.  According to their third quarter 2009 financial releases, fifty percent of the company's total income derives from the twenty percent of its enrollees who are covered through state contracts to provide Medicaid and Medicare services.

UnitedHealth's net earnings in third quarter 2009 were up over 13% from the previous year, to $1.04 billion.

Why does a company that clears $4 billion a year have the right to decide how much a child's life is worth?

Hawaii -- deficit plus stimulus funds shouldn't equal a bigger deficit, should it?

The Honolulu bureau of the Associated Press ran a great article a week ago on the impact Hawaii's $1 billion budget deficit was having on education and others in need.

According to the official web site for the American Recovery Act, which tracks the money going out to the states as well as what the states admit to having, Hawaii reported receiving $811.9 million by October 30, 2009. 

The feds say they've awarded Hawaii $1.2 billion in contracts, grants and loans.  Over $1 billion of that is in grants.  One source I found said Hawaii had only received about 40% of the funds, but it's approved. 

Not to mention that the $1 billion projected deficit is by 2011, and we're talking money in the bank now with lots more on the way.

I've asked CMS (the Medicaid federal regulatory people) about this and have been met with evasive responses.  Having personally lived in Washington D.C. for 8 years, I can tell you that evasion from government employees is not a positive indication.

So with education being cut by a day a week and elderly and disabled people being threatened with institutionalization, what's the money being spent on?

CDREA publishes new CMS definitions of case management for kids with disabilities

The Children's Disability Rights Education Association (CDREA) has published an article on the latest definition of case management services issued by the federal Medicaid regulatory agency.

The broad scope of required activities that must be included in "case management", coupled with the role that the individual or their designated health care decision maker play in determining these activities, gives families more control over the services they need than ever before.

While the document in question related specifically to children covered by EPSDT (i.e., under the age of 21 and receiving Medicaid), similarly written documents have been issued that cover individuals of any age who receive Medicaid because of their enrollment in what's called a "Medicaid waiver" program. 

In the state of Hawaii, for instance, anyone currently enrolled in the state's QExA program, and therefore receiving their Medicaid services through either Evercare or Ohana, plus anyone currently enrolled in the states Developmentally Disabled waiver program, are entitled to case management services.

Hawaii's decimation of its aged, blind and disabled population worsens

Hawaii's two gold-digging for-profit insurance companies handling Medicaid have sunk to new lows. A Mom on Oahu got a call from her medically fragile son's Medicaid for-profit company. With no written notice, the company was downgrading her son from 54 hours a week of RN level nursing to 14 hours a week of a CNA. A little boy's life will be in danger beginning November 15, while no one knows what Hawaii Governor Lingle has done with the $154 million in stimulus funds she's received that can only be spent on Medicaid. The boy's services are provided as part of a deal Governor Lingle's administration negotiated with UnitedHealth Group and WellCare Health Plans for the two out-of-state, for-profit companies to take over medical care for the state's "aged, blind and disabled" populations. More than 37,000 people on February 1 were dumped from their pay-for-service Medicaid care into the merciless grip of UnitedHealth and WellCare, with no information from the state about this essential distinction in their care. As part of the negotiations, UnitedHealth and WellCare had to agree to make no cuts in home and community services for their 37,000 new clients for 90 days. After a Kauai mom filed complaints with the federal DHHS Office for Civil Rights and Center for Medicare and Medicaid Services (CMS, the division that regulates Medicaid), a wave of new cuts in August was halted. A little boy's life will be in danger as of November 15, when the final slash of 88% of his home care services takes effect. Where are our Medicaid stimulus funds? Background information on these two for-profit Medicaid managed care companies continues to be updated. Unitedhealth has paid out over $1.3 billion in fines, penalties and settlements to 9 states and their own shareholders since January 1, 2008. Their subsidiary Evercare was fired by the state of Texas in May, 2009. Fines and settlement just in 2009 include $536,000 to Missouri in August, $750,000 to Georgia in November, $457,000 to Colorado in October, $3 million to Texas in October, $630,000 to Texas in January, $350 million and a separate settlement for $50 million to New York in February. Yet on October 20, Unitedhealth posted a 13% increase in their profit from the same quarter a year earlier. The company's private plan membership dropped by 6%, but enrollment in its Medicaid and Medicare programs had increased by 14%. I'm not an economist but it seems that the aged, disabled and blind community is not unprofitable. We already reported Wellcare has paid out over $90 million in restitution and fines since May 2009. We recently learned that in February 2009, WellCare was ordered by the CMS to stop taking enrollment in certain of their Medicare plans. A letter from CMS to WellCare noted "WellCare was one of the overall worst performers among all plans,” and “WellCare’s complaints are three times the national average.” CMS kindly released WellCare from the suspension on November 4, 2009, in time for the company to participate in the federal open enrollment period. Also on November 4, "WellCare reported higher-than-expected third-quarter earnings Wednesday, swinging to a profit of $28.7 million, or 68 cents per share, from a year-earlier loss of $18.2 million, or 44 cents a share." Hawaii desperately needs an audit done of where the state's stimulus funds for Medicaid have gone if the companies running our Medicaid can make these kind of profits, while paying the sort of fines and settlements we've described, while at the same time cutting a toddler's home nursing services by 88%.

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?

Medicaid, IEPs and the right to case management services

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:

1. Making referrals for and/or coordinating medical or physical examinations and necessary medical/dental/mental health evaluations.
2. Making referrals for and/or scheduling EPSDT screens, interperiodic screens, and appropriate immunization, but NOT to include the state-mandated health services.
3. Referring students for necessary medical health, mental health, or substance abuse services covered by Medicaid.
4. 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.
5. Gathering any information that may be required in advance of medical/dental/mental health referrals.
6. Participating in a meeting/discussion to coordinate or review a student’s needs for health-related services covered by Medicaid.
7. Providing follow-up contact to ensure that a child has received the prescribed medical/dental/mental health services covered by Medicaid.
8. Coordinating the delivery of community based medical/dental/mental health services for a child with special/severe health care needs.
9. 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.

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.

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.

Please, if you're the parent of a kid with special needs, read this

For the first time in my history as the mom of a kid with disabilities, we parents have the ability to get our kids all the home and school support services, technology and therapies that their doctors think are medically necessary. We can go straight to the source, rather than wait around for our local Department of Education or Voc Rehab to get their paperwork together. All you need is a prescription, the evaluation and a letter of necessity, and you turn it over to your Medicaid case worker. Better yet, some of the corporations such as Dynavox, handle all the paperwork for you. The timing is perfect. The government has dumped over $28 billion into state coffers that can only be spent on Medicaid, with more on the way. Schools have been given more money as well, with a particular emphasis being given to using it on assistive and augmentative technology. The percentage of a state's total Medicaid budget which will actually come out of state accounts is somewhere between 10-35%. I did a rough calculation, and for a state paying the highest percentage, for every $10 million of its own money the state does NOT spend, the state loses about $28 million in immediate jobs and services. The only problem is, in too many states, nobody knows what happens to those stimulus bucks once they disappear into some new, very deep coffers. If your state is continuing to cut medicaid services for your child, if your school is trying to cut service hours from the IEP, then there's a good chance there are some questions about how your stimulus tax dollars are being spent (and even if they are at all). Last week, the Government Accounting Office issued a report focusing on how states are using their stimulus funds. The report called into question the "quality and reliability" of data that the states are giving the feds about how and on what they're spending their stimulus bucks. Meanwhile, Department of Health and Human Services Kathleen Sebelius released an additional $600 in stimulus funds to the states just between September 17 and 30, 2009. Nobody in the media, nobody in the government, is paying attention to the mystery of how states are spending their stimulus dollars. CMS refers all calls on the subject to its Baltimore headquarters. Three states are under some sort of federal investigation for violating federal Medicaid law and the Americans with Disabilities Act, and 7 more have civil suits filed or in preparation alleging similar violations. A friend of mine with disability law experience and I have put together a group called Children's Disability Rights Education Association. Our role is to help parents and caregivers take greater control over their child's health and education. As CDREA we have a petition up, calling on DHHS to require complete accountability from the states, and to ensure priority is given to restoring Medicaid service budget cuts made since July 1, 2008. These cuts have unfairly targeted children as well as adults with disabilities who need skilled care to live at home with their families. Similar problems are plaguing state stimulus funding received for education. I just found this source, but the correlation between what's happening with money for both special education and medicaid home support systems is an atrocious example of discrimination against children, as well as adults, with disabilities. Please consider signing our petition, and forwarding it to your friends.

If you had a company, would you hire back an employee who had stolen $40 million from you?

Because that's what our federal government has done, awarding a national Medicare contract to a company that has just paid $80 million in restitution and penalties to Florida for defrauding their state Medicaid plan, $10 million to the SEC for something else, and even $120,000 to the Florida Election Commission for ""questionable campaign contributions." Wellcare states on its website that the company provides managed care services exclusively for government-sponsored healthcare programs, focusing on Medicaid and Medicare. Some of the states where WellCare is providing Medicaid managed care services are Hawaii, Ohio, Georgia, Florida, Arizona, New York, Louisiana, Texas, Indiana, Illinois and New Jersey. This company that has paid out over $90 million just in the past five months to various federal and state authorities also reported that second quarter 2009 net income was 236% higher than it was in second quarter 2008. That represents a jump from $11.1million in April-May-June 2008 to $37.0 million in the same three months of 2009. Another way to look at WellCare's profit is that the company spent $1.5 billion on medical benefits and receieved $1.8 billion in revenue from premiums. How much of that $300 million profit (just for 3 months) could have been directed back to Medicaid services if these services were not administered by a for-profit company? UnitedHealth Group operates public sector health care programs (i.e., Medicaid and Medicare) in 23 states, under a variety of names. UHG's revenue from premiums for the second quarter of 2009 was $19.7 billion, of which 83.6% was spent on medical services. That's a handy profit for three months of $3.23 billion. That isn't breaking out employee plans from state plans, but in this particular economy, that kind of profit isn't something to be sneezed at. Just in 2009, UnitedHealth Group has paid out over $1 billion in fines to New York, California and Missouri, plus another $62 million in the two preceding years. For profit companies such as WellCare and United Health should not be allowed to administer federally funded programs where their company profits are literally taking necessary medical services away from babies. Decisions on issues such as "medical necessity" should not be left up to a profit-driven company. I live in Hawaii, where our Medicaid program, including EPSDT, is run by WellCare and UnitedHealth Group.

Feds Investigate Hawaii Medicaid Cuts -- News for disability rights advocates

Hawaii's Medicaid program has come under federal scrutiny by one Federal department, and is pending scrutiny by another. The severe budget cuts that Hawaii has been making in its DDMR waiver program, and the way Medicaid is functioning under the new managed care (for profit) system that began February 1, are the objects of this scrutiny. On June 29, I filed a complaint with the Office for Civil Rights of the Department of Health and Human Services (OCR). On August 26, the San Francisco regional office of OCR notified the San Francisco regional office of the Centers for Medicare and Medicaid Services (CMS) of the issues involved. A lot of health and other professionals are relatively unaware of the hugely important role CMS plays in the day to day operation of our state Medicaid and Medicare programs. CMS wrote the last formal interpretation of the Maintenance of Effort (MOE) clause of the American Recovery Act which allowed the states to get away with making substantial medicaid service cuts and still receive stimulus funds. CMS decides how Medicaid and Medicare are supposed to function and issues letters to the states or rulings printed in the Federal Register, and then these items become law for states to follow. CMS isn't set up to handle individual complaints, but is now watching how the Hawaii Medicaid due process system functions, to ensure it functions the way CMS expects it to. As the parent of a child whose home services have been threatened with substantial cuts, I have the security of knowing that the state will have to follow federal law in these hearings. They're not going to be able to just "make it up as they go", as has happened so often in the past. Part of this process is ensuring that EPSDT, which entitles children with special health care needs to a much broader scope of services than normally provided under Medicaid, also functions as intended. From the standpoint of education advocates, this can provide a tremendous opportunity. DHHS has written manuals on how EPSDT and IDEA are supposed to function jointly to meet all the educational, medical and social needs of children with disabilities. They published a brochure in May 2003 with detailed instructions on how state education departments can bill EPSDT for services, and another brochure in 2004 specifically describing how EPSDT services are to be incorporated into the IEP.

Medicaid eligible children with disabilities are entitled to receive medical services in the school setting, paid for by Medicaid, if two important requirements are satisfied. First, the school/school district must be a participating Medicaid provider. Second, the services must be written into the child’s IEP/IFSP, which automatically makes them considered medically necessary.

Since the Hawaii schools are Medicaid providers, there is no reason for Hawaii's children who are eligible for Medicaid to continue to suffer from DOE denials of services. This issue of the integration of EPSDT with the IEPs will continue under federal scrutiny. Doctors can write letters of medical necessity and submit these, along with a prescription, to the child's Medicaid provider (either Evercare or Ohana). Medicaid is then supposed to provide it via the funding they are receiving from the state. That part of the system isn't functioning well right now - but that's how we can all help get things working correctly here. Linda Nuland-Ames and I have formed the Children's Disability Rights Education Association. Our first activity is an online petition to DHHS Secretary Kathleen Sebelius, calling for full transparency of how states are spending their Medicaid stimulus funds and ensuring that a priority is given to using these funds to replace Medicaid services which have been cut since July 1, 2008. According to DHHS, the states have already received over $28 billion in stimulus funds that can ONLY be spent on Medicaid. My state, Hawaii, has already received over $131 million (with more on the way). No one seems to know how it is being spent, and no one wants to answer my question why it isn't being spent restoring Medicaid service cuts. CMS tells me they are also working to have someone made responsible at the state level for communicating between families that have their services cut, and both the Hawaii Department of Health and Department of Human Services. CDREA will reach out to families whose services have been cut to ensure their concerns are heard and receive the consideration they so urgently deserve. Please join us in these actions. Summer Harrison Linda Nuland-Ames Children's Disability Rights Education Association

Are 10 of our 50 states committing daily violations of the civil rights of our citizens with disabilities?

I've been having to devote time to my little girl's seizure issues, and my own struggle with our state waiver program over proposed cuts in her nursing hours. So I missed the comment from UCP from my last article and didn't see it until now. I hadn't had a chance to post yet about Alaska's HCBS programs being shut down by CMS, which brought to ten the number of states with either civil suits pending or ongoing federal investigations over cuts made to HCBS services. That means twenty percent of our state governments are possibly committing daily violations of the civil rights of their citizens with disabilities. This is just dead wrong.

New documents on Scribd regarding EPSDT and recent CMS rulings

I've just posted quite a few new documents to Scribd. The good news (and I'll write more about it later) is that CMS has now endorsed the following statement it made in May of 2003:

The Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) provision is Medicaid’s comprehensive and preventive child health program for individuals under the age of 21. ESPDT services include periodic health screening, vision, dental, and hearing services. The Medicaid statute also requires that states provide any medically necessary health care services listed in section 1905(a) of the Social Security Act (the Act) to an EPSDT recipient even if the services are not available under the state’s Medicaid plan to the rest of the Medicaid population.

The Individuals with Disabilities Education Act (IDEA) was passed to “assure that all children with disabilities have available to them… a free appropriate public education which emphasizes special education and related services designed to meet their individual needs.” The IDEA authorizes federal funding to states for medical services provided to children through a child’s Individualized Education Program (IEP), including children that are covered under Medicaid. In 1988, section 1903(c) of the Act was amended to permit Medicaid payment for medical services provided to Medicaid eligible children under IDEA and included in the child’s IEP.

While schools are legally liable to provide IDEA-related health services at no cost to eligible students, Medicaid reimbursement is available for these services because section 1903(c) of the Act requires Medicaid to be primary to the U.S. Department of Education for payment of the health-related services provided under IDEA. Medicaid covers services included in an IEP under the following conditions: • The services are medically necessary and included in a Medicaid covered category (speech therapy, physical therapy, etc.); • All other federal and state Medicaid regulations are followed, including those for provider qualifications, comparability of services and the amount, duration and scope provisions; • The services are included in the state’s plan or available under EPSDT; and • The medical service must be provided to a Medicaid eligible student.

Put this together with the 1980 DOE pamphlet on EPSDT and the schools, and new horizons for getting our kids the help they need have opened.