Highlights

• 7-Day EA Diversion Funds Depleted
• Proposal to Cut RIDE Fare
• MH Parity Rules Issued
• Air Travel ADA Rules
• Weak Assisted Living Regs
• MH Facility Enforcment Limited
• MassHealth CarePlus to Cover Transportation
• CommCare Coverage Extended
• ACA Transition Provider Toolkit
• State Welfare Reform Bill

Sections

• Program Highlights
• Health Care Coverage
• Policy & Social Issues
• Of Clinical Interest

Questions, comments about the newsletter? Contact Ellen Forman, x6-5807.

State Freezes Admissions at Arbour-HRI

State regulators have prohibited a Brookline psychiatric hospital from admitting any patients, citing deteriorating conditions and an immediate risk to patient safety.

Health officials took the unusual action on November 21, 2013 against Arbour-HRI, part of a chain of mental health hospitals and clinics that has been repeatedly cited in Massachusetts and other states for understaffing and poor training of workers.

Inspectors made a surprise visit to Arbour-HRI in October, after receiving a report about a female patient being forcibly searched, an incident that state Mental Health Commissioner Marcia Fowler described in an interview Monday as “a very serious human rights violation.” The inspectors identified a range of problems, including dirty conditions and untrained or inexperienced staff, she said.

As an initial step, the Department of Mental Health slightly reduced the number of patients that the 66-bed hospital was allowed to treat at a given time. But when Arbour-HRI did not properly address the problems that regulators had identified, the state halted admissions altogether.
Lizbeth Kinkead, the department’s licensing director, wrote to Arbour’s owner, Universal Health Services, that she was concerned that patient care at the hospital was “substantially compromised.”

The hospital, which reported a 32 percent profit on operations last year, has until the end of the month to submit a proper plan of correction or the department will begin the process of suspending its license, the letter said. Arbour Health System spokeswoman Judy Merel said the hospital was working on a new corrective action plan to be submitted to the state before the deadline.

Arbour-HRI is part of Arbour Health System, which operates seven inpatient facilities and 13 clinics in the state. Universal Health Services, a public company with nearly 200 psychiatric centers around the country, owns Arbour Health.

-See the full Boston Globe article...

-See also accompanying story National Reviews of Centers Rare in Mental Health

Seven-Day Temporary Emergency Accommodations Program Funds Nearly Depleted

The Seven-Day Temporary Emergency Accommodations Program (SDTEA) (a program of the state Department of Housing and Community Development or DHCD) is close to running out of funds.

SDTEA is a new sub-program under the Residential Assistance for Families in Transition (RAFT) program that was created this fiscal year to address concerns that families who were at imminent risk of staying in places not meant for human habitation were being excluded from the state's Emergency Assistance (EA) family shelter and services program. SDTEA was the compromise response, and has been an important resource for extremely low-income families who are not yet/will not be eligible for EA. SDTEA, administered by the RAFT providers and subcontracted entities, provides up to 7 days of shelter, while a family explores other housing options, and if none are identified, the family may re-apply for EA shelter.

The program began operating on September 3, 2013. In the first two months, this important program protected about 300 families from sleeping in unsafe places. 53% of these families then qualified for EA shelter, while another 11% qualified for RAFT.

Currently, the Department of Housing and Community Development (DHCD) is able to spend up to $500,000 from the RAFT line item in fiscal year 2014 on SDTEA. While the fiscal year will run until the end of June, the appropriation is expected to be exhausted by early December. Advocates are asking the Legislature to take action to ensure that this program does not end, just as the coldest time of the year begins, by allowing DHCD to exceed the $500,000 cap. 

See the SDTEA fact sheet.  

- Adapted from Ask Your Legislators to Take Action to Continue to Protect Families Experiencing Homelessness by Extending the New SDTEA Program, e-mail from Kelly Turley, Mass Coalition for the Homeless, November 14, 2013 and the SDTEA Factsheet.

MBTA Proposes Fare Cut for The Ride

MBTA officials plan to roll back the fare for The Ride from $4 to $3 — a significant triumph for advocates who have argued that a doubling of the fare last year had a grave impact on the lives of  people with disabilities who rely on the T’s special door-to-door service.

The announcement came November 26th at a meeting of the Massachusetts Department of Transportation’s finance committee. “It’s never too late to do the right thing,” said the T’s general manager, Beverly A. Scott.

She said the reason for reducing the fare is simple: Ridership data, and testimony from riders themselves, made it clear the fare increase hurt the disabled community more than officials expected.

Members of the finance committee said they would recommend the T’s proposal be approved by the full MassDOT board of directors at its Dec. 11 meeting. If approved, the $3 fare would probably go into effect by mid-January, MBTA assistant general manager Charles Planck said.

At the meeting, the panel also discussed efforts to urge Ride-eligible users to take trains or buses for some trips.  T officials have begun a series of workshops for people with disabilities to educate them on how to use the train system, and have extended a pilot program that offers them free Charlie Card passes.

Alan G. Macdonald, a member of the MassDOT board, encouraged the transit agency to continue the policy, saying, “I think every time an eligible Ride user uses a fixed route, it’s a savings to the system.”

-See the full Boston Globe article...

Parity Rules Issued for Mental Health Care Coverage

The Obama administration issued rules this month requiring most health insurers to provide similar coverage for people with mental and physical health problems. The federal rules will extend protections to people covered by self-insured plans, typically offered by large employers and not regulated by the state. Passed in 2008, the legislation was the culmination of more than 20 years of advocacy on the part of The American Psychiatric Association (APA)  and other allied organizations. Although an interim final rule was issued in 2010, it did not carry sufficient legislative weight, resulting in "weak and inconsistent application," said APA president Jeffrey Lieberman, MD  in a statement.

Many insurers, he said, tried to skirt the legislation via a variety of methods that included "vague medical necessity standards, discriminatory payment practices leading to inadequate provider networks, bureaucratic delays in services requests, failing to provide treatment equity for those suffering from mental illness or addiction, and complicated appeals processes."

The final rule implements the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act and ensures that health plan features such as copays, deductibles, and visit limits are generally not more restrictive for mental health/substance use disorders benefits than they are for medical/surgical benefits.

It also includes specific additional consumer protections, such as the following:

• Ensuring that parity applies to intermediate levels of care received in residential treatment or intensive outpatient settings; (such as eating disorder or substance abuse treatment)
• Clarifying the scope of the transparency required by health plans, including the disclosure rights of plan participants, to ensure compliance with the law;
• Clarifying that parity applies to all plan standards, including geographic limits, facility-type limits, and network adequacy; and
• Eliminating the provision that allowed insurance companies to make an exception to parity requirements for certain benefits on the basis of "clinically appropriate standards of care," which clinical experts advised was not necessary and which is confusing and open to potential abuse.

In Massachusetts, implementation is partly underway. State-regulated insurers, including plans for individuals, small businesses, and Medicaid recipients, must send a notice to customers by Jan. 1 explaining their rights to equal coverage and a new state process for filing a grievance if they believe they have wrongfully been denied mental health care.

With those steps and the state’s near-universal health insurance coverage, Massachusetts is seen as further ahead than many states in providing access to mental health care. But advocates here say there is plenty to be done.

-See the full Boston Globe article...
-See the full Medscape article...

US Alters Rules to Aid Disabled Air Travelers

Disabled travelers should find it easier to access airline websites in the future under a new set of rules the government issued in November.

Airline website pages which have core travel information and services must be accessible to the disabled within two years, the Department of Transportation said, and all pages on airline websites must within three years be readily available to people with disabilities.

The new regulations also require airline ticket agents to disclose — and offer — Web-based discount fares to customers unable to use their sites because of a disability.

Another new rule gives airlines more flexibility in how they transport manual, folding wheelchairs onboard, making it possible for them to carry up to two wheelchairs in the cabin, the department said. In addition to being able to stow a wheelchair in a closet, airlines will also be allowed to strap a second chair across a row of seats.

Closets also must have signs saying wheelchairs have priority over other baggage.

Under pre-existing rules, airlines are required to provide free, prompt wheelchair assistance, upon request, to passengers with disabilities. The department said this includes helping passengers to move between gates and make connections to other flights.

-See the full Boston Globe article...

Assisted Living Barely Regulated Nationally

Over the past two decades, assisted living has undergone a profound transformation. What began as a grassroots movement aimed at creating a humane and innovative alternative to nursing homes has become a multibillion-dollar industry that houses some 750,000 American seniors. Assisted living facilities, at least initially, were meant to provide housing, meals and help to elderly people who could no longer live on their own.

But studies show that increasing numbers of assisted living residents are seriously ill and that many suffer from dementia. The workers entrusted with their care must manage complex medication regimens, safeguard those for whom even walking to the bathroom can be dangerous, and handle people so incapacitated they can be a threat to themselves or others.

Yet an examination by ProPublica and “Frontline” found that, in many states, regulations for assisted living lag far behind this reality.

Despite the growing demands on care in assisted living, most states set the entry bar low for facility workers, requiring little in the way of education or qualifications. In Minnesota and 13 other states, administrators don’t need high school diplomas. Caregivers can be as young as 16 in Illinois. Facilities in some states, Colorado among them, are not required to have even one licensed nurse on staff.

Under most state regulatory schemes, assisted living companies are also free to decide how much staff their facilities should have. Just 14 states set staffing ratios; in Mississippi, facilities must have at least one staffer on duty for every 15 residents during daytime hours and one per 25 at night. In California, by contrast, facilities housing as many as 200 seniors need no more than two workers on the overnight shift. Neither of them is required to have any medical training. And one of them is allowed to be asleep.

Compared with nursing homes, assisted living facilities in many states receive relatively little outside monitoring. Under federal guidelines, nursing homes are supposed to be inspected at least once every 15 months. For assisted living, the interval between inspections can be five years in some states. South Carolina and five other states require no regular inspections.

In many parts of the country, assisted living operators face few consequences for even the most serious lapses in care. All states have the power to shut down troubled facilities, but they typically do so only as a last resort and after years of problems. Most states can impose fines for violations of safety standards, but they seldom carry much sting – in California, facilities routinely pay as little as $150 in cases in which the state found residents had died as a result of poor care.

While consumers can go online and compare the track records of nursing homes on a government web site, few such resources exist for assisted living. Twenty-two states still don’t post inspection records online, requiring residents to visit state offices to view them on paper or file public records requests.

-See the full Propublica/Frontline article...

-See  chart from that article: State-by-State: Assisted Living Regulations

Cited in/Linked from: NSCLC In Review, National Senior Citizens Law Center, November 13, 2013.

GED to Become More Rigorous and Fees to Increase

A new version of the GED (General Educational Development or high school equivalency) exam rolls out in January. With the new version, test takers must use a computer instead of paper and pencil. The test itself will be more rigorous and cost more — at $120, the price in some states will be significantly higher than previous versions. Some places may subsidize all or part of the cost. 

Americans who passed part, but not all, of the GED test are rushing to finish the test  before their previous scores are wiped out. About 1 million people could be affected. Test takers have been warned for more than a year about the approaching Dec. 31 deadline to complete the test. States and localities are phoning people, and thousands of letters have gone out — including to 32,000 Californians who passed parts but not all the test in the last two years.

Some critics have challenged the price increases and the mandate that test takers use a computer — issues that affect many people living in poverty.

This is the first upgrade since for-profit Pearson Vue Testing acquired a joint ownership interest in the GED Testing Service. For 70 years, the service has been run by the nonprofit American Council on Education.

-See the full Boston Globe article...

National Reviews of Centers Rare in Mental Health

Pennsylvania health officials in 2011 temporarily stopped a mental health center from admitting children or teens after they found poor conditions, excessive use of physical restraints, and too few people caring for patients, according to state records. In a psychiatric hospital in Chicago the same year, investigators found that violence was “an everyday occurrence,” fueled by understaffing. And when regulators in North Carolina last year took steps to revoke the license of a residential treatment center after violence at the facility, they cited, among other things, incompetent clinical staff.

All three facilities were owned by Universal Health Services, the largest operator of freestanding psychiatric centers in the United States. Universal has a history of staffing problems at its hospitals around the country, but this record has rarely factored into reviews by state regulators — including in Massachusetts.

The company runs seven inpatient facilities and 13 clinics in the state, under the name Arbour Health System, which in recent years have been repeatedly cited for not having enough nurses and for allowing unlicensed or unsupervised workers to treat people. Massachusetts health officials have not examined whether Universal’s corporate practices might have contributed to violations by Arbour, which owns 1 in 5 psychiatric hospital beds in the state and serves large numbers of poor and disabled people.

“Someone should be saying, ‘What’s their track record elsewhere?’ ” said Christine Griffin, executive director of the Disability Law Center, a nonprofit group that represents people with mental illness.

The federal government may now be undertaking a broader review. The facilities in Pennsylvania, Illinois, and North Carolina, along with eight more of Universal Health Services’ nearly 200 psychiatric centers, have received subpoenas from the inspector general at the Department of Health and Human Services, who investigates fraud or abuse of government health care programs, according to the company’s latest quarterly report filed with the Securities and Exchange Commission. None of the facilities are in Massachusetts, but two in Florida also are being investigated by the Department of Justice criminal fraud section.

Psychiatric care is widely seen as underfunded, with advocates and industry leaders frequently calling for higher payments from insurers. But Arbour’s Massachusetts hospitals last year reported profits of between 15 percent and 32 percent, according to company reports filed with the state. By comparison, two other large freestanding psychiatric hospitals in Massachusetts, for-profit Bournewood Hospital and nonprofit McLean Hospital, reported single-digit surpluses.

In an interview in August, state Mental Health Commissioner Marcia Fowler said Arbour Health System is “of great value to the Commonwealth,” because the hospitals care for some of the most difficult patients in the state’s care. Arbour facilities include specialized units for patients who may be violent, people with developmental disabilities, and children and teens in crisis.

The company’s disciplinary record in Massachusetts did not raise red flags, Fowler said. She declined, through a spokesman, to be interviewed for this story or comment on whether her agency should consider Universal’s national record when reviewing care at Arbour.

Arbour spokeswoman Judy Merel refused Globe requests to speak with company executives. Merel said in an e-mail that Arbour hospitals, like all Universal facilities, regularly “assess several key patient safety and quality metrics to ensure we are providing the highest quality care and treatment to our patients.”

Universal’s central clinical services office also tracks quality measures, she said, and hospital staffing needs are monitored to maintain “therapeutically appropriate levels.”

-See the full Boston Globe article...

Massachusetts Legal Clinics for the Homeless

The Lawyers Clearinghouse is a Massachusetts nonprofit that connects homeless and low-income individuals with pro bono legal aid. They conduct legal clinics for the homeless at three Boston shelters: Pine Street Inn, St. Francis House and the Cardinal Medeiros Center. People using shelter services, as well as others who are income-eligible, are welcome at these clinics where they can meet with lawyers from area law firms and get advice about civil, non-domestic matters such as housing, bankruptcy and social security benefits.

For more information, shelter contacts, and future dates/events see: www.lawyersclearinghouse.org/for-shelter-guests/massachusetts-legal-clinic-for-the-homeless/

New addition: 2018-2019 Clinic Schedule

Hilary Vaught
Communications Coordinator
Lawyers Clearinghouse
617.778.1948

(via Mass Coalition for the Homeless distribution list 11/14/13.)

Senior Aide Community Service Employment Program (SCSEP)

The Senior Community Service Employment Program (SCSEP) is a federal job training program for unemployed low-income seniors age 55 or older who face barriers to employment. SCSEP places seniors in part-time paid community service assignments for on-the-job training, with the goal of giving them job search skills, work experience, and training they need to find unsubsidized jobs in the private sector.

Some benefits include an Individualized Employment Plan (IEP) that is developed with a career counselor; paid on-the-job training in a community service assignment (senior center, school, library, etc.) for at least 20 hours per week at minimum wage; referrals to support services such as food programs, housing assistance, and transportation; job search training and resume assistance; and confidential annual physical exams (not required but available for free).

To be eligible, you must be:

• age 55 or older
• unemployed
• legally able to work in the U.S.
• have total family incomes no greater than 125% of the Federal Poverty Guidelines

• for an individual, the 2013 income limit is $14,363
• for a couple, the 2013 income limit is $19,388
• for other family sizes, scroll down to the 125% FPG table on the MassLegalServices web site: http://www.masslegalservices.org/content/federal-poverty-guidelines-2013

• able to perform the job tasks required by host agencies

You can find Senior Community Service Employment Programs in your area by using the America's Service Locator search tool from the U.S. Department of Labor:

• Find an Older Worker Program – SCSEP: http://www.servicelocator.org/program_search.asp?prgcat=1&officeType_1=14
• Or call the Helpline: 1-877-US2-JOBS (1-877-872-5627); TTY:1-877-889-5627

Financial Coaching Program: The Midas Collaborative

The nonprofit Midas Collaborative offers a remote Financial Confidence and Coaching Program. This program aims to help Massachusetts residents realize their financial goals and develop skills to better manage their finances, create savings and assets, and make informed decisions about their financial options throughout life. Trained and accredited Midas coaches provide high-level financial coaching services to Massachusetts residents via Skype, phone, and e-mail.

The majority of Midas’ clients are below 80% of the Area Median Income, but they are happy to work with people at all income levels. The service is targeted to those unable to utilize in-person financial coaching services and classes because of geographic or transportation issues, prohibitive work schedules, language barriers, and/or physical disabilities. Once screened for the program, clients will be matched with a coach and offered between one and three free 50-minute sessions.

Midas coaches have professional accreditation by the Association of Financial Planning, Counseling, & Education (AFCPE). The coaches do not advise on particular products or services but will refer clients to trusted resources and information. The program currently offers coaching and referral services in English, Spanish, Somali, Armenian, and Polish. The coaches have flexible schedules and can work with clients after hours and on weekends.

These services are meant to complement the resources offered online at its financial education website, www.MassSaves.org, and the in-person services of Midas member organizations and partners throughout the state. Examples include Action for Boston Community Development, Cambridge Housing Authority, Springfield Partners for Community Action, and many more. See a list of members here: http://massassets.org/members#Full. These member organizations offer a variety of in-person financial coaching services in various towns throughout the state.

Contact information:
The Midas Collaborative
20 Linden Street, Suite 288
Allston, MA 02134
Coaching and Confidence Line (toll-free): 1-855-721-7575
Coaching@MassAssets.org
www.massassets.org  
www.masssaves.org

New Details of Upcoming MassHealth “CarePlus” – Including Transportation Coverage

As part of bringing the state into compliance with the Affordable Care Act,  the MassHealth Basic and Essential programs will sunset and a new coverage type  “MassHealth CarePlus” will  begin operation.  This change is, as of this writing, scheduled to take effect January 1, 2014.  CarePlus will serve adults 21-64 with income under 133% FPL & not eligible for Standard as pregnant, disabled or parents/caretaker relatives.

Benefits

We’ve previously reported that in preparation for this change, MassHealth Basic and Essential have started offering hospice coverage as this will be a covered service under CarePlus.  A benefits comparison between MassHealth Standard and CarePlus can be found at Benefits in CarePlus Compared to Standard (at Masslegalservices.org). 

CarePlus will provide coverage similar to MassHealth Standard for most basic health needs including behavioral health services, DME and Dental care. It also offers improved coverage over the MassHealth Essential and Basic coverage types that it will be replacing.  Members enrolled in CarePlus will be able to access non-emergency transportation (PT-1s), a benefit formerly only available to those with MassHealth Standard or MassHealth CommonHealth.  It also appears that there will be at least partial coverage of chronic hospital and Skilled Nursing Facility services, which were not covered under Basic and Essential. Hearing aids will also be covered.

Similar to under the Essential and Basic coverage types, Adult Day Health, Adult Foster Care and Day Habilitation and the PCA program will NOT be covered services. However, there is a new route to upgrade to MassHealth Standard (see advocacy tip below). 

Coverage Will Be Through Managed Care Organizations (MCOs).

Six MCOs were selected through a competitive process to serve MassHealth CarePlus members, including: Boston Medical Center HealthNet Plan, CeltiCare Health Plan of Massachusetts, Fallon Community Health Plan, Health New England, Neighborhood Health Plan, and Network Health.

MassHealth will automatically enroll existing eligible members in CarePlus, and members will have the opportunity to select among the CarePlus MCOs, when they receive their new enrollment guides in December.

Important Advocacy Tip: “Medically Frail” May Upgrade to Standard

Under CarePlus, there is a new route to upgrade to MassHealth Standard for those considered “medically frail”.  By definition CarePlus members haven’t meet the criteria as disabled (or they’d already qualify for Standard). But there may be some in this group who have significant health care needs. If an individual can document the need for a service covered by MassHealth Standard, but not CarePlus, such as for a PCA, they may be able to upgrade to Standard without having to meet the full disability criteria. 

Similarly, those receiving behavioral health services through MBHP whose providers only participate in a PCC plan, may retain their PCC plan membership by requesting Standard coverage.

Advocates note MassHealth will not automatically screen for this and members will not be prompted to apply, so this is an important advocacy opportunity.

-See the press release...

Commonwealth Care Coverage Extended for Existing Members

As part of Affordable Care Act Implementation, the state’s Commonwealth Care program is scheduled to sunset and be replaced by ConnectorCare as of January 1, 2014. The state recently announced that in an effort to allow Commonwealth Care members the opportunity to take full advantage of the federal open enrollment period, the state will extend Commonwealth Care coverage for existing members through the end of March, if necessary.

Please note, that Commonwealth Care members with incomes above 133% of the federal poverty level (FPL) as well as AWSS (Aliens with Special Status- legal aliens such as those under the 5 year bar) members at any income still MUST re-apply before the end of this open enrollment in order to transition to their new ACA-compliant coverage.

Current Commonwealth Care members with income below 133% of FPL, excluding AWSS, will automatically transition into a MassHealth Coverage type on January 1, 2014.

See the Factsheet.

-Adapted from: Important Notification about the Health Connector's Commonwealth Care Program, MA Health Care Training Forum, November 20, 2013.

ACA's Spanish Website Sign-Up Delayed

The launch of the Spanish version of HealthCare.gov  has been delayed.  The site now provides basic information, but still doesn't allow users to apply for insurance coverage online. U.S. Health and Human Services spokeswoman Joanne Peters told The Associated Press that the administration now plans a quiet launch of the Spanish enrollment tools in early December without much advertising.

That leaves Spanish speakers getting help by phone from bilingual call center operators or in person from bilingual enrollment counselors while they wait for an online option. An estimated 10.2 million uninsured Latinos may be eligible for coverage through the marketplace. Most of them speak English or are bilingual, but 3.7 million rely on Spanish.

Hispanic community organizations have shouldered much of the burden of answering questions from Spanish speakers, hiring additional staff to answer phones and taking calls on Spanish language radio shows.

People who live in the United States illegally aren't eligible for coverage under the Affordable Care Act, but they must enroll any children born here or face a tax penalty. Luvia Quinones of the Illinois Coalition for Immigrant and Refugee Rights said it's a common fear among mixed status families that signing up their children for insurance will prompt an unwelcome visit from immigration authorities.

Last month, U.S. Immigration and Customs Enforcement announced it would not use health insurance enrollment information for enforcement.

-See the full Associated Press story...

Snarls in Retooled Mass. Insurance Site

Since the state relaunched its insurance website (www.MaHealthConnector.org) Oct. 1 to comply with the national law, it has had persistent problems: links lead nowhere, technological failures lock users out or deliver inexplicable error messages, and consumers endure long wait times to speak with customer service representatives, who sometimes offer little more than a suggestion to try again later.

Leaders of the Massachusetts Health Connector, the independent agency that runs the marketplace, say they are working around the clock to address the problems. They say they have brought in experts to help engineer fixes and plan to double the number of people working the hot line by the end of this week.

The Connector’s Facebook page is full of complaints from consumers, many of whom said they support the state and national health care laws ideologically but are incensed by an uncooperative website and by the fact that the old, functional state system is gone.

About 105,000 people who have state subsidized coverage, through a program called Commonwealth Care, must enroll in a new plan in the coming months, and many more people want to shop for insurance. The website is not yet accepting online payments. The Connector also moved the deadline by which the 105,000 people enrolled in Commonwealth Care must select a new plan — to March 31, allowing three more months.

In the first days of troubleshooting the website, Connector spokespeople said that they were fixing relatively minor glitches and that some of the more significant problems were related to difficulty accessing the troubled federal data hub. But weeks later, many of the most common complaints are about the state website itself.

Health Care for All, a consumer advocacy group, has been hearing complaints that the website is slow to load or finicky. Kate Bicego, the consumer assistance program manager, said she is confident the state is doing what it can to fix it.

“We’re asking people to take a deep breath,” she said. “No one has lost coverage.”

But that is a concern. Some people with nonsubsidized plans through the Connector’s Commonwealth Choice program must reenroll in coverage by year’s end if their plan expires. And some consumers with canceled commercial plans are looking to shop for coverage through the state market and avoid a gap in coverage.

-See the full Boston Globe story... 

ACA Transition Provider Toolkit

The Massachusetts Health Connector and MassHealth have released a helpful guide that allows one to determine whether a person who is currently enrolled in some form of subsidized health coverage may experience a change in coverage under the Affordable Care Act transition. The guide will tell you what coverage they will likely transition to, and whether he or she should be automatically moved to a new program, needs to re-apply or will experience no change.
To use the chart, you’ll need:

• The name of the person’s current health insurance program
• Their immigration status
• Their age
• Their income

A person who re-applies for health insurance through the Health Connector must apply, enroll, and make a payment before December 23, 2013 or risk losing health insurance.

Provider Transition Toolkit:  http://www.mass.gov/eohhs/docs/masshealth/provider-services/aca-transition-toolkit.pdf

Other Groups

• People Currently in Young Adult Plans (YAPs)- Coverage ends December 31st. Must reapply for coverage and pay premium at least five business days before the end of December (Monday, December 23rd).
• For People Currently in Commonwealth Choice- All Commonwealth Choice members must reapply for coverage before March 31st, 2014. Coverage end date depends on the date they purchased a health plan. Call the Health Connector to find out the coverage end date.
• For People Over Age 65 in Medicare- The ACA primarily impacts those under age 65.  One does not need to do anything to keep Medicare! The Health Insurance Marketplace (Health Connector) offers new dental benefits for those interested in purchasing one. Otherwise, they should not shop for health insurance on the Health Connector. The regular Medicare Open Enrollment period is going on concurrently with the ACA transition, possibly leading to confusion. Those on Medicare who want to  change their Medicare supplement and/or Medicare Part D plan should do so through the Medicare Open Enrollment process by December 7, 2013.

-This section adapted from: HCFA's ACA Coverage Transition Guide

Reminder:  Learn more about ACA implementation at a presentation by Kim Simonian, MPH, Director for Public Payer Patient Access at Partners HealthCare - Community Health, at the combined Social Service and Case Management meeting December 5th, from 10-11:30 a.m., O’Keeffe auditorium.

Medicare D:  Most People Don’t  Switch Plans, At a Cost

With the open enrollment period for switching Medicare Part D drug plans nearing its end (December 7), the Kaiser Family Foundation has released two reports that both question the design of the plans and the inattention of 23 million of us who have them.

Signing up for all the other parts of Medicare — hospitalization, out-patient physician visits — requires one effortless phone call. But Part D is a far more complicated hybrid, administered by private insurance companies on behalf of the government. Each year Part D enrollees are asked to reconsider their plan’s monthly premium, its annual deductible, its authorized pharmacies and its formulary of drugs. Branded or generic? In what dosages? How many tablets per month? Which drugs are in which price tier?

Almost nine in 10 of us don’t bother to switch, Kaiser has found.  Kaiser resisted making hard-and-fast conclusions about inertia among Plan D beneficiaries, and the study notes that it is possible some are signaling satisfaction with the status quo. But far more likely, the authors said, is that the confusing array of plans is “too much choice’’ and this kind of “competitive model’’ is not working.

After years of observing consumer behavior, private insurance companies “have less incentive to keep costs down” in Part D plans, they added — since that doesn’t seem to matter to the consumers. The unintended consequence is that both beneficiaries and the government are paying more than necessary.

The studies also found that most plans had acquired many additional wrinkles over time. More tiers of drugs in the formularies, some allowed and others not and each with its own pricing. More plans that required in-network pharmacies or bigger penalties for going out of network. In other words, an even more complicated algorithm than in years past. And the study found that some plans, that had begun with reasonable premiums jacked them up from one year to the next, in what looks a lot like bait-and-switch.

Both Kaiser studies cited polls and focus groups — qualitative, not quantitative evidence — saying beneficiaries would prefer “a simpler system.’’ This view is supported by behavioral economic research, the report said, “which suggests that decision makers who face a wide range of choices have more difficulty making decisions, make poorer choices, and may in fact fail to make any decision whatsoever.’’

-See the full New York Times New Old Age blog...

Medicare Premiums and Deductibles Hold Steady for 2014

The Centers for Medicare & Medicaid Services (CMS) has announced that the 2014 Medicare Part B premium will remain $104.90 per month, the same as in 2013. The Part B deductible will also remain the same at $147. 

CMS credits measures introduced by the Affordable Care Act (ACA) for the stable cost sharing beneficiaries will experience next year.

This news adds to the growing list of improvements to Medicare made possible by the ACA, such as cost savings on prescription drugs for beneficiaries in the doughnut hole. According to CMS, “…since the Affordable Care Act provision to close the prescription drug donut hole took effect, more than 7.1 million seniors and people with disabilities who reached the donut hole have saved $8.3 billion on their prescription drugs.” Remember, the doughnut hole began to close in 2010, when the Affordable Care Act was signed into law. Since then, it has closed more each year, and in 2020, the doughnut hole will be eliminated altogether.

Read the CMS announcement from October 28, 2013.
Read more about doughnut hole savings.

-For more on ACA savings provisions see the full Medicare Watch article...

Medicare Reminder: Star Rating System Allows Some to Disenroll Mid-Year

Medicare uses a Star Rating System to measure how well Medicare Advantage (Medicare managed care programs) and Part D prescription drug plans perform. Ratings range from one to five stars, with five being the highest and one being the lowest score. Plans get separate star ratings in each individual category reviewed and then Medicare assigns an overall rating.

Star ratings can be found in the Medicare Plan Finder tool (www.medicare.gov/find-a-plan) or by calling 800-MEDICARE. A plan’s star rating is only one factor to look at when comparing plans.

Medicare will send a letter to those who are enrolled in a plan that gets one or two stars for three years in a row. Members will not be removed from the plan but, may want to carefully consider their options. Those enrolled in such plans that do not make a change during Fall Open Enrollment, will be allowed to switch from low-rated plans to a plan that has received three stars or more at any point during the year.

Learn more about star ratings on Medicare Interactive.

-See the full Medicare Watch article...

State Welfare Reform Bill Pending

A bill is currently working its way through the Massachusetts legislature that would make significant changes to the state’s welfare programs, including subsidized housing. The bill  includes provisions to require adult recipients who are not enrolled in a full-time secondary school or granted a work exemption to seek employment through a “pathways to self-sufficiency program,” to imprison repeat food stamp traffickers for up to 10 years, and to crack down on out-of-state residents collecting payments.

Currently the bill is in conference committee which will seek to reconcile the different versions passed by the House and Senate.

Similar amendments to both the House and Senate versions of the bill would exclude certain non-citizens, including many with lawful status, from state public housing (currently state housing is open to all regardless of immigration status). Both versions would also raise the age at which one was no longer required to meet work requirements from 60 to 66.

 
 “We really have deep concerns,” said Rebekah Gewirtz, government relations director for the state chapter of the National Association of Social Workers.  She said disability provisions in the bill could disqualify thousands of vulnerable families from receiving benefits, and a section requiring people to seek employment before applying for assistance fails to take into account “circumstances that could prevent them from holding a job at certain times in their lives.”

The bill in its current form requires adult applicants “who are not exempt from the work requirement to conduct an initial job search prior to receiving cash assistance unless the applicant has good cause for not participating as determined by the [state], which may include disability.” Both of the current versions of the bill do NOT provide child care or transportation assistance related to this job-search requirement.

Protections against fraud in the bill include suspending benefits of recipients who fail to notify the state of an address change; requiring citizens who receive assistance to provide their Social Security number within three months of being assigned a placeholder number; and requiring adult recipients to provide evidence of job searches.

Mass Law Reform Institute has released a preliminary summary of the House bill, which includes comparing it to the Senate bill.

Please stay tuned for the final law. 

-See the full Boston Globe article...

-Adapted from the above and an e-mail from Kelly Turley, Mass Coalition from the Homeless, November 14, 2013.

Opinion: The ACA Fix Won’t work- But the Point is to Change the System

President Obama recently announced an administrative fix to the ACA for the problem of millions of Americans discovering that the plans they “liked” were being canceled: an extension for one year that allows insurers to keep people on health care plans that the Affordable Health Care act would not have allowed.

The cancellations had posed a real problem for the Obama administration, because they flew in the face of what many believe is a core promise of health care reform: that you could keep your policy if you liked it.

The Affordable Care Act changes the way insurance is regulated. It declares that many services are now mandatory. This included a lot of preventive care, as well as maternity care. Any policies that don't provide these services will no longer be offered. Other policies had very low annual or lifetime limits. These, too, have to go away. Anyone who had one will need to find a new policy. It's very likely that newer policies, with more robust benefits, will be more expensive.

That will make many people unhappy.

Plans change from year to year, premiums change from year to year, coverage changes from year to year, and deductibles, copays, and co-insurance change from year to year. They always have. It has never been the case that you could be guaranteed that your plan would exist -- as it does today -- for as long as you would like.

The truth of the matter is there is no easy solution here. Disrupting the current system isn't a bug of health care reform; it's a feature. It's what was supposed to happen. All reform will do so.

Letting healthy people keep these plans (because most of those in the pre-Affordable Care Act individual market are healthier) and stay out of the exchanges will raise the premiums for everyone else, and thus the amount the government will have to pay in subsidies. Forcing insurance companies to continue to offer old plans in a new marketplace could wind up hurting their bottom line significantly.

Obama's administrative fix, much like the House bill, allow plans offered this year to remain in place if people want them. But that will just shift blame to the insurance companies when they cancel them. For many of the reasons above, they won't want to keep them going.

The real problem here, and one that few are addressing, is that the old health care system isn’t that good. We wanted to change it. Doing so means that it, well, changes. If we liked our old health care system, we could keep it.  But we didn’t, and so at some point we’re going to have to accept a new one.

-See the full opinion piece on CNNcom...

Looking at it Another Way: The Insider/Outsider Problem

Obamacare was always going to be a hard sell because it is an attempt to fix an insider-outsider problem. At root, its supporters do not think it right for a country as rich as America to be home to tens of millions of people who do not have health coverage, or who have such skimpy insurance that they risk financial ruin if they fall gravely ill.

As it so happens, I think that is a powerful argument. But it is politically perilous, because in a world of finite resources outsiders can only be helped by asking insiders to share a bit, whether through rationing or by paying higher premiums. And a lot of Americans feel like insiders because they have what feels like pretty good health care (even if it costs them more than they may realize, via lost wages).

Republicans get this. For sure, they sometimes talk in windy abstractions about keeping government bureaucrats out of American doctors’ offices (nobody is allowed to mention government-funded Medicare for the elderly at this point). They also say doomy things about bankrupting the country by creating a gigantic new entitlement program for the sick and indigent.

But mostly Republicans have focused on appeals to today’s insiders: warning them that they will be worse off once Obamacare is in force. Those appeals work, because there is something to them. The future of health care in America inevitably involves more rationing and less consumer choice. Indeed it has to. Whether or not you believe Obamacare has a decent chance of putting health care on a more sustainable footing, something has to give. But it is going to hurt. If Obamacare is going to offer affordable coverage to sicker, poorer people without bankrupting the private insurers, then it will have to stick others with the bill. Some will pay more, some will get less, and lots of young, healthy Americans will have to buy insurance for the first time.

Supporters of Obamacare believed that their opponents were misreading the American population and its balance of health-care outsiders and insiders. They looked at millions of Americans on cheap or cheap-ish health plans bought on the individual market. They shuddered at those plans’ skimpy benefits or high deductibles, and thought: quite a lot of those people are outsiders who do not realize it. If we can get them into health exchanges under Obamacare, some of them will discover that they qualify for new subsidies (turning them into happy insiders) and some of them will gain better health cover for not much more money (turning them into more or less grudging insiders).

Alas, this reason to plough on did expose Team Obama to a timing problem. In the most optimistic scenario, it was always going to take time for those individual policyholders to feel the benefits of Obamacare. That explains Mr Obama’s lethal, pre-election dancing around the truth, when he said that anybody who liked their current plan could keep it. What he meant was: anyone with a plan that a rational person would like will get to keep that plan. That seemed a safe enough promise to make, because most who today get insurance from their employers will not be entering the Obamacare exchanges. And in the run-up to an election the temptation to omit that caveat was too great to be resisted.

That has now come back to bite them. Team Obama misread the balance of outsiders and insiders in the American population. They failed to see how many people on cheaper, skimpier plans would feel like insiders with something to lose when they received a letter from their insurance company, telling them their current plan would vanish on December 31st.

A last irony. The plan, of course, was for those with cancelled plans to hop onto the Obamacare websites and discover that they were, in fact, insiders in the new system. But the website is not working.

-See the full Economist blog...

Both pieces cited in/linked from: HEALTH CARE WEEKLY UPDATE, Barbara Roop & John Goodson, Health Care for Massachusetts, November 15, 2013.

Screening Children for Mental Health Issues May Not Guarantee Care

Six years after the state launched an unprecedented effort to address the mental and developmental needs of young children, doctors in Massachusetts are screening more children for behavioral health concerns than any other state.

Nearly 7 in 10 Massachusetts children under age 6 in low-income families were screened in 2011 and 2012 — more than twice the rate in the United States as a whole, according to data released this month by the Massachusetts Budget and Policy Center as part of the national Kids Count report. Doctors in North Carolina, which had the second highest rate, screened just over half of this group of children.

But, has the success of pediatric screening led to better behavioral health care in the state? That’s a question researchers and physicians say they can’t yet answer.

Certainly doctors and families can’t address a child’s condition if they don’t know about it. But getting the children who are flagged by the screenings connected to the care they need remains a major challenge.

Doctors and advocates cite a host of obstacles: inadequate mental health training for primary care doctors, a dearth of pediatric psychiatrists, and persistent stigma around mental illness that makes some families reluctant to talk about the issues their child is facing.

It is difficult to track how often a positive screening leads to appropriate follow-up care; the state Medicaid program has begun reviewing data but has not released any figures.

-See the full Boston Globe article...

Jail Takes a Hidden Toll on City’s Blacks

Incarceration is creating a social and economic crisis in Boston’s black community, leaving families without breadwinners, creating single-parent households, and depressing incomes, according to a survey by the Center for Church and Prison, a Dorchester research and resource center.

The findings build on other research that identifies the disproportionate effect of the war on drugs on the black community and the emphasis in the criminal justice system on punishment, rather than rehabilitation.

Blacks and Hispanics make up less than 20 percent of the state’s population but more than 55 percent of its prison population, according to the survey, which sought to use empirical data to illustrate the side effects of incarceration on Boston’s black community, he said.

It is not unusual for residents of Roxbury, Mattapan, and Dorchester to know someone in prison and for the leading cause of imprisonment to be a nonviolent drug offense, according to the survey.

 “Prevention, intervention, or reentry —it doesn’t concern the average person until they’re impacted by it themselves,” said the Rev. William E. Dickerson, pastor of Greater Love Tabernacle in Dorchester, which participated in the survey.  More than 95 percent “of the inmates are coming back to somebody’s communities, so it would make sense for us to make sure they come home whole and not fragmented.”
Plans for reentry, such as job training and searching for affordable housing, should begin the moment someone is imprisoned, Dickerson said. While some jails, such as those in Suffolk and Norfolk counties, have GED programs, parenting courses, and vocational classes, others are cutting such programs, Dickerson said.

Councilor Tito Jackson, who represents Roxbury on the Boston City Council, said the issue of addiction is not discussed nearly enough during conversations about criminal justice reform.

“Addiction is a very important factor in terms of why so many people are involved in crimes,” Jackson said. “This issue of addiction — and depression and trauma, these mental health issues that go untreated — oftentimes end up being treated in the most expensive and worst-prepared facilities, which are those of jail and prisons.”

The Center for Church and Prison’s study found that 45 percent of crimes committed by those incarcerated were drug offenses. The Suffolk sheriff’s office reports that about 42 percent of inmates have some form of mental illness.

-See the full Boston Globe article...

ICU Stay Linked to Long-term Cognitive Impairment

People who survive life-threatening illness often have long-term, disabling cognitive impairment. However, few studies have addressed this serious complication.

The investigators studied 821 adults with respiratory failure or shock in the medical or surgical intensive care unit. At baseline, 6% had cognitive impairment, and 74% developed delirium during their hospitalization. Using the Repeatable Battery for the Assessment of Neuropsychological Status and the Trail Making Test, Part B, the investigators tested global cognition and executive function at 3 and 12 months after discharge.,

Global cognition scores at 3 months were 1.5 SD below the population means (or similar to scores for patients with moderate traumatic brain injury) in 40% of patients. Scores were 2 SD below the population means (or similar to scores for patients with mild Alzheimer disease) in 26% of patients. Younger patients as well as older patients had these deficits, which were persistent. At 12 months, 34% of all patients had scores similar to those with moderate traumatic brain injury, and 24% had scores similar to those with mild Alzheimer disease.

Longer duration of delirium was an independent predictor of worse global cognition at 3 months (P = .001) and at 12 months (P = .04) and of worse executive function at 3 months (P = .004) and at 12 months (P = .007). In contrast, sedative or analgesic use was not consistently associated with cognitive impairment at 3 and 12 months, after adjustment for delirium.

Viewpoint

This large, multicenter, prospective cohort study with a diverse patient population had several limitations. These included inability to test patients' cognition before their illness, inability of some patients to complete all cognitive tests, and possible bias related to unmeasured confounders.
Nonetheless, this study showed that cognitive impairment after critical illness is very common and may persist in some patients for at least 1 year.

Cognitive deficits were more likely in patients with a longer duration of delirium. Although the mechanisms underlying this association are still unclear, delirium is associated with inflammation and neuronal apoptosis, which may result in brain atrophy. These findings suggest that interventions to reduce delirium could have the potential to reduce brain injury associated with critical illness.

-Adapted from: ICU Stay Linked to Long-term Cognitive Impairment. Medscape,  Nov 06, 2013.