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MGH Community News |
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MGH Community News |
| January 2015 | Volume 19 • Issue 1 |
Highlights
Sections Social Service staff may direct resource questions to the Community Resource Center, Lindsey Streahle, x6-8182. Questions, comments about the newsletter? Contact Ellen Forman, x6-5807. |
ABLE Act Will Allow Certain SSI Recipients Additional Savings
President Obama recently signed a law that allows children with disabilities and adults disabled before age 26 to open tax-free savings accounts to pay for certain life expenses. Funds in these special accounts would also not count towards Medicaid and Social Security benefits asset limits. The Achieving a Better Life Experience, or “ABLE” Act allows people with disabilities to save money for future needs, “You are touching the lives of a lot of Americans,” said Representative Ander Crenshaw, a Florida Republican. “You can save money to go to college or to retire, but they couldn’t save money to use for disability expenditures.... It was forced impoverishment.” The saga of the ABLE Act also shows grassroots movements can achieve change — but it can take years to happen. The disability community is easy to overlook and causes languish without relentless lobbying and the right mix of political support. Sponsored by Senators Bob Casey (D-PA) and Richard Burr (R-NC), the bill attracted unusual bipartisan support, including co-sponsorships by both Senate Majority Leader Harry Reid and Minority Leader Mitch McConnell. ABLE amends the federal tax code to allow tax-free savings accounts to help finance disability-related needs. They are similar to Section 529 college savings accounts and eliminate, for ABLE accounts, the current $2,000 cap on savings for individuals with disabilities. Under previous law, people with disabilities who saved more than $2,000 fail to qualify or risk the loss of their Supplemental Security Income (SSI), Medicaid and other benefits. Funds deposited in ABLE accounts would have to be used exclusively for disability-related expenses. ABLE accounts will be immediately available because of the need for the Internal Revenue Service to define qualifying expenses and complete other regulatory steps. The ABLE Act has its limitations. If a savings account balance exceeds $100,000, for example, there will be an offset for an individual’s SSI check. It mostly helps people who have money to save, tax policy analyst Howard Gleckman pointed out. |
Several states are now moving to create ABLE accounts providing state tax income benefits, consistent with the development over the years of college savings accounts at both the federal and state levels. Massachusetts created a state ABLE program in 2014.
Details A “qualified disability expense” means any expense related to the designated beneficiary as a result of living a life with disabilities. According to an analysis by the Congressional Budget Office, eligible expenses could include:
Are there limits to how much money can be put in an ABLE account? The maximum total annual contributions by all participating individuals, including family and friends, is $14,000. The amount will be adjusted annually for inflation. The total limit over time that could be made to an ABLE account will be subject to the individual state and their limit for education-related 529 savings accounts. Many states have set this limit at more than $300,000 per plan. However, for individuals with disabilities who are recipients of SSI and Medicaid, the ABLE Act sets some further limitations. The first $100,000 in ABLE accounts would be exempted from the SSI $2,000 individual resource limit. If and when an ABLE account exceeds $100,000, the beneficiary would be suspended from eligibility for SSI benefits and no longer receive that monthly income. However, the beneficiary would continue to be eligible for Medicaid. States would be able to recoup some expenses through Medicaid upon the death of the beneficiary. How is an ABLE account different than a special needs or pooled trust? An ABLE Account will provide more choice and control for the beneficiary and family. Cost of establishing an account will be considerably less than either a Special Needs Trust (SNT) or Pooled Income Trust. With an ABLE account, account owners will have the ability to control their funds and, if circumstances change, still have other options available to them. Determining which option is the most appropriate will depend upon individual circumstances. For many families, the ABLE account will be a significant and viable option in addition to, rather than instead of, a Trust program. -See the full Boston Globe column.-See the Fact Sheet from AutismSpeaks.org -See ABLE Accounts: 10 Things You Must Know, from the National Disability Institute
New Law Gives Massachusetts Fathers Paternity Leave Under a new law signed by former Gov. Deval Patrick the day before he left office, Massachusetts men will be guaranteed eight weeks of unpaid paternity leave. Essentially, the new change makes the state's existing maternity leave policy gender neutral. Supporters say it will give fathers a chance to bond with their new babies. It will also help gay couples who adopt a child. "It was updating the law to the 21st century to say it should be a parental leave act, not a maternity leave act," said Monica Halas, an employment lawyer at Greater Boston Legal Services, which advocated for the change. The new law goes into effect April 7, 2015. Under existing federal law, new mothers and fathers are both eligible for up to 12 weeks of unpaid leave to take care of a newborn. But that law, the Family and Medical Leave Act, only applies to businesses with more than 50 employees. The state law, which requires eight weeks of unpaid time off, applies to businesses with six or more employees. A second provision of the law requires a company to put in writing any extension they grant to the eight week leave. This provision was the result of a 2010 Supreme Judicial Court decision that found against a housekeeper who was verbally granted a two-week extension by her employer but then lost her job when she tried to return to work. The court found that due to the extension, the woman lost her right to job protection. -See the full Masslive.com article.
Filing Taxes and the Affordable Care Act For the first time, federal tax filers will have to report information about their health insurance during the previous year. For most people who get health coverage through work or through government programs like Medicaid, it will mean simply checking a box. Others who got insurance through state and federal marketplaces will have to file a new form, while people who received subsidies will have to provide more detailed information. The subsidies were based on projected incomes, so families will need to report if actual incomes were higher or lower. If higher, they might have to pay back some of the subsidy, either through a smaller tax refund or a payment. If their incomes were lower, they might qualify for a larger tax refund. People who didn't have health insurance last year face fines unless they qualify for a waiver, which requires more paperwork. For 2014 tax returns the fine is generally the greater of 1% of household income above the individual filing threshold or $95 per adult ($47.50 per child), limited to a family maximum of $285. Expect Long Waits If You Call the IRS These unfamiliar procedures come at a time when, according to IRS Commissioner John Koskinen, budget cuts are forcing the agency to reduce taxpayer services and other functions. The tax agency says only half of the 100 million people expected to call this year will be able to reach a person. Callers who do get through may have to wait on hold for 30 minutes or more to talk to someone who will answer only the simplest questions. Congress cut the IRS by $346 million for the budget year that ends Sept. 30. Koskinen says the agency's $10.9 billion budget is its lowest since 2008. When adjusted for inflation, the budget hasn't been this low since 1998, he said. Republicans in Congress adamantly oppose Obama's health law, so some have been working to starve the IRS of funds just as its role in implementing the law ramps up. It won't work, Koskinen said in an interview. The agency, he said, is required by law to help implement the health program. "The only places we have discretion are in information technology, tax enforcement, customer service." Where to Get Help
The IRS wants you to visit its website. The agency has devoted a section to answering questions about the health law: www.irs.gov/Affordable-Care-Act/ . Koskinen's advice to taxpayers with questions: Don't call the IRS unless you absolutely have to. A decision guide and links to supplemental forms can be found at: http://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Health-Care-Law-and-Your-Tax-Return -See the full New York Times article. NSTAR is renewing its warning that scams targeting utility customers across the country continue to affect customers in Massachusetts as well. While some scams include impersonators trying to obtain account information and entry into customers’ homes, others include scammers falsely telling residents and businesses their utility company will shut off their power unless payment is made immediately. While the scammers keep changing the scenario they use to pressure customers into making hasty, often large payments to keep the power on, the scheme to get the money remains basically the same. A caller tells the targeted customer the only way to keep the power on is to pay quickly using an untraceable pre-paid debit card (such as the Green Dot MoneyPak cards or Vanilla Reload Network card) . NSTAR representatives never demand instant payment over the phone and don’t require the use of pre-paid debit cards. Customers can verify they are speaking with an NSTAR representative by asking for some basic information about their account. NSTAR customer service representatives will always be able to verify the name on the account, the account address, and the exact past due balance. NSTAR employees rarely make unsolicited house visits. Some exceptions include accessing utility equipment to ensure the safe and efficient operation of the distribution system, or if there is a reported safety concern. Always decline any door-to-door offer from someone claiming to be an NSTAR employee. NSTAR representatives will never arrive unsolicited asking for electric account information. Customers should never provide the information if someone represents himself in this way. For those considering switching to a third-party electricity supplier, a complete list of licensed competitive suppliers in Massachusetts can be found online at mass.gov. Customers should only provide their NSTAR account information if dealing with licensed suppliers and want to make a switch. “If any of our customers suspect someone is impersonating a representative of NSTAR, whether on the phone or in-person - even if they show identification, please contact us immediately or call the local police.” said Penni Conner, Senior Vice President and Chief Customer Officer at Northeast Utilities, NSTAR’s parent company.
New DPH Requirement- Distribute Information About Palliative Care, Hospice and Medical Orders for Life Sustaining Treatment Massachusetts now requires health care providers to notify terminally ill patients of the full range of care options, including advance medical directives, palliative care, hospice care and medical orders for life sustaining treatment (MOLST). Effective December 19, 2014, Department of Public Health (DPH) regulations require all licensed hospitals, clinics and long-term care facilities to distribute information about these care options to every appropriate patient.." “Appropriate Patient” is defined in the regulations as a patient whose attending health care practitioner has:
This new requirement may be met by distributing DPH's new brochure, Know Your Choices: A Guide for Patients with Serious Advancing Illness to appropriate patients or by creating materials that include similar information. The brochure is available in nine additional languages (Arabic, Cape Verdean, Chinese, Haitian Creole, Khmer, Portuguese, Russian, Spanish and Vietnamese). The brochure explains advance directives (including health care proxies), palliative care, hospice care and the MOLST protocol. Facilities will be required to create a policy to identify appropriate patients who should receive the information. Further information is available on the DPH website and at Honoring Choices Massachusetts. -Adapted from Massachusetts Improves Access to Information About Palliative and Hospice Care and More, Margolis & Blooom, LLp, January 20, 2015 andDPH Circular Letter DHCQ- 14-12-623,December 10, 2014.
Trans Lifeline is a hotline staffed by transgender people for transgender people. Trans Lifeline is primarily for transgender people experiencing a crisis. This includes people who may be struggling with their gender identity and are not sure that they are transgender. While their goal is to prevent self harm, they welcome the call of any transgender person in need. Trans Lifeline volunteers are all trans identified and educated in the range of difficulties transgender people experience. The US hotline number is (877) 565-8860. Professionals seeking more information about their work are encouraged to call Greta Martela at (415) 483-5361 rather than the hotline. Trans Lifeline volunteers are generally available during the following times:
-From http://www.translifeline.org/
Affordable Food- Two Dollars A Bag Program Fair Foods’ Two Dollars a Bag program is not new, but may be a lesser known and underutilized resource. The program operates through a network of volunteers in distribution sites at over twenty locations in churches, schools, public housing and senior centers across Boston. For a two dollar donation, a family receives about 15 pounds of groceries. They have no eligibility requirements, no registration, and no ID checks. There is no application process. Individuals wishing to participate should look up the location and date of the Fair Foods: Two Dollars a Bag site (and bring their own bags). Participants may take as many bags as needed for themselves, friends, or family. No one is turned away for an inability to pay. See the Metro Boston Schedule. More information at: http://fairfoods.org/ -Thanks to Melanie Cohn-Hopwood and Judy Sinsheimer for reminding us about this program. Margolis & Bloom is an elder law, estate, and special needs planning law firm with four locations in eastern Massachusetts. They offer several free legal guides that are available for download with registration for their weekly e-letter. The guides include these titles:
-See the full list and register to download.
Family Strife over Elder Care? Consider an Elder Mediator One or both parents requiring care can create serious stresses and conflicts within families. Sometimes disagreements and misunderstandings over elder care or inheritance issues can lead families to break apart, affecting descendants for generations. To avoid this, elder mediation is available to resolve family disputes that otherwise may go unaddressed or lead to costly and traumatic litigation. A successful resolution can preserve family ties to the benefit of the entire family tree. The mediator doesn't make any decisions and doesn't take sides. Instead, the mediator listens to the issues, keeps the family focused on the goals, encourages consideration of all the options, and helps clear up misunderstandings and address hurt feelings. Through this process, the family can come up with answers to problems or ways of solving conflicts. The idea is not to have a winner or loser, but to have a solution everyone is happy with. At the end of the mediation, a settlement agreement may be drawn up to memorialize the parties' understanding. Because it is not a legal proceeding, the agreement is not binding, but the idea is to create an agreement that everyone will be happy to follow. Mediation takes time, costs money and there's no guarantee of success. But skilled mediators can often bring families back together who otherwise would break apart forever. This can be well worth the time and expense and may be much cheaper and more pleasant than the alternative. To learn more, visit the following websites: -See the full article from Margolis & Bloom.
Medicare Reminder- Differences Medicare Advantage and Medicare ACOs In December, the AARP Public Policy Institute published an article on Medicare Accountable Care Organizations (ACOs). Established by the Affordable Care Act, ACOs are networks of hospitals, doctors, and other health care providers. These networks share a primary goal— to coordinate and improve the quality of, expand access to, and reduce the cost of care for beneficiaries with Original Medicare. Medicare ACOs are unlike Medicare Advantage (MA) plans in two important ways. First, MA plans have defined provider networks and may impose utilization controls, like prior authorization, on access to particular services or prescription medicines, but ACOs do not. Beneficiaries who receive care from an ACO are encouraged to see doctors within their ACO, but have the option to seek care from any doctor that is part of Original Medicare. Second, Medicare beneficiaries proactively enroll in an MA plan. Original Medicare beneficiaries who are “attributed” to an ACO, however, may not know they are part of the ACO. Medicare beneficiaries’ quality of care measures appear to have improved for those beneficiaries receiving care from ACOs. Citing empirical research, AARP notes that quality of care improved on multiple measures, including timely access to care, coordination between specialty and primary care, and whether the patient was offered the doctor’s visit notes at the end of an appointment. See the AARP Public Policy Institute article. More on ACOs There are also ACOs outside of Medicare. In general, are ACOs HMO-style managed care by another name? A recent New York Times column dissected that question and concluded that “accountable care organizations, by and large, are devised more in response to the shortcomings of H.M.O.s than as a copy of them.”. ACO.-like contracts typically do not rely on full capitation. Instead, they usually put providers at risk for a portion of the cost of care; that risk is shared with insurers, somewhat sidestepping a major financial challenge to providers under 1990s-style capitation. Another big difference is that 1990s H.M.O.s and capitation contracts didn’t require providers to meet quality targets to receive full payment. Today’s accountable care organizations tie bonus payments to quality, a feature intended to mitigate against providers sacrificing quality for lower cost. Finally, accountable care organizations are developing in a climate of far better information resources — electronic medical records and techniques for using the data they collect for quality measurement and improvement — than existed in the 1990s. Sources and for More Information
Medicare Reminder- Can I Buy Medigap if Disenrolling from Medicare Advantage? Disenrolling from a Medicare Advantage plan during the Medicare Advantage Disenrollment Period (MADP) does not necessarily give you a protected right to purchase a Medigap. Remember, a Medigap is a supplemental insurance policy that is sold by private insurance companies to help pay Medicare copays, coinsurances, and deductibles. (Learn more about what Medigap plans typically cover on MedicareInteractive.org.) This insurance policy works only with Original Medicare. Under national law, you only have the right to buy a Medigap policy if you are 65 years old and enrolled in Medicare, and if you buy your policy during a protected enrollment period. When you turn 65 and enroll in Medicare Part B, you have a six-month open enrollment period during which Medigap companies must sell you a policy at the best available rate, regardless of your health status and cannot deny you coverage. If you are age 65 or over, national law also gives you a protected enrollment period to buy most Medigap policies within 63 days of when you lose or end certain kinds of health coverage. This includes:
Finally, if you have a Medicare Advantage plan, Medicare SELECT policy or PACE program and you move out of the plan's service area, you have the right to buy most Medigap policies. Note that national laws regulating Medigaps do not apply to people under the age of 65 who are eligible for Medicare due to disability or ESRD diagnosis. If you do not meet the criteria listed above, you may encounter problems when trying to purchase a Medigap during the MADP. Companies can refuse to sell you a policy, or may only sell you one if you meet certain medical requirements. You also may need to pay a higher premium and wait six months before the Medigap will cover pre-existing conditions. Keep in mind, many states follow the national rules explained here for Medigap policies, but some allow people to more flexibility to enroll in Medigap. Some states also apply Medigap protections to people under age 65 who qualify for Medicare based on a disability. Check out the rules in your state before purchasing a Medigap by, calling your State Health Insurance Assistance Program (SHIP). To find the contact information for you SHIP, visit www.shiptalk.org. -From Can I purchase a Medigap during the Medicare Advantage Disenrollment Period?, “Dear Marci” e-mail, Medicare Rights Center, January 26, 2015.
AARP Public Policy Institute Examines Transitions from Expansion Medicaid into Medicare A new report from AARP Public Policy Institute (PPI) examines the challenges faced by low-income adults who enroll in expanded Medicaid coverage and later must transition into coverage under Medicare. Under the Affordable Care Act (ACA), states can expand Medicaid coverage to adults ages 19-64 earning up to 138% of the Federal Poverty Level (FPL). The Supreme Court ruled in 2012 that Medicaid expansion is a state option. To date, 28 states and the District of Columbia have chosen to expand the program to adults under age 65 who in most cases would not have qualified before the expansion. Individuals enrolled in expansion Medicaid have little or no out-of-pocket costs when accessing covered health care, prescription medications, and other Medicaid-covered services, and these individuals rarely pay a premium. When a person turns 65 or becomes eligible for Medicare under the age of 65, however, that person generally can no longer qualify for expansion Medicaid and must instead be covered under Medicare. The AARP PPI report highlights additional costs for low-income adults transitioning from expansion Medicaid into Medicare, and discusses restrictive income and asset limits associated with programs available to help low-income Medicare beneficiaries with their Medicare premiums and cost sharing. Specifically, the report highlights the Medicare Savings Programs (MSPs), all of which pay a Medicare beneficiary’s Part B premium, and automatically qualify that individual for assistance with Medicare prescription drug costs, through the Extra Help program. Eligibility for full Medicaid benefits and for MSPs for individuals age 65 or older (and those with Medicare who are under 65) are often stricter and can count a person’s assets, whereas assets are not counted to determine eligibility for expansion Medicaid. See the AARP Public Policy Institute report. -From Medicare Watch, Volume 6, Issue 3, Medicare Rights Center, January 22, 2015.
Reminder - Affordable Care Act Open Enrollment Ends February 15 Affordable Care Act Open Enrollment ends on February 15, 2015. But remember that those seeking financial assistance for insurance coverage can apply at any time during the year.
*A Qualifying Event allows one to shop within 60 days of certain life events including (not an exhaustive list):
Enrollees will have sixty (60) days to enroll in a Health Plan from the date of a mid-year life or qualifying event. -Source and for more information: Health Connector Policy: Mid-Year Life Events or Qualifying Events
Connector Plan Names and Plan Participation We are starting to see patients present with some of the new 2015 Affordable Care Act plans offered through the Connector. There are many different plan names with different levels of coverage. Staff may view this reference list on our ACA Sharepoint site of all the health plans available on the Massachusetts Connector, and our participation in the plan network for each one. -Adapted from e-mail correspondence from Kim Simonian, MPH, Director for Public Payer Patient Access, Partners HealthCare - Community Health, January 20, 2015.
MassHealth & Health Connector Updates Reminder- Health Connector Preferred Web Browsers The Health Connector recommends using Chrome 30, Firefox 30, or Internet Explorer 10 or later. Those using older web browsers will find that some functions may not work as they are supposed to and can result in strange behaviors when browsing the site or completing an application. New MassHealth Application and Verification Fax Number The fax number used to fax Massachusetts Application for Health and Dental Coverage and Help Paying Costs paper applications (ACA-3) and other documentation (CDF, NDF, PSI, ARD, verification documents-except those related to Identity Proofing*) is changing. New Fax Number: 857-323-8300 The old fax number, 617-887-8770, will continue to work for the next few months to allow assister organizations time to incorporate the new number in their business processes. They encourage everyone to start using the number immediately while working to re-program all auto faxes, change any internal training documents, and update materials, correspondence and websites. *The fax number for Identity Proofing remains 617-887-8745. On January 15, 2015 approximately 30,000 MassHealth members who had an eligibility determination through the old HIX system were sent annual renewal notices. These notices were sent to the head of household and explain that the family has 60 days, until March 15, 2015, to submit a new application through the new HIX system. Here’s a sample notice. Members who will be 65 or older by March 31, 2015 will be sent a cover letter and SACA-2 form to complete. They have the same 60 day time period to complete that form as those under age 65. On March 15, 2015 all members who do not have an eligibility determination through the new application on MAhealthconnector.org will be sent a termination notice stating that their coverage will end on March 31, 2015. In order to avoid any gaps in coverage, members must apply by that date. If they miss that date, they will be able to apply anytime during the year but may experience coverage gap. As most of these members applied last year online through the old system, they will not be sent a paper application (ACA-3) to complete. Instead, the renewal notice encourages them to apply online but also provides options for applying through other means. The notice also provides information regarding how to obtain assistance from Navigators or Certified Application Counselors. All members who have already applied through the new application on MAhealthconnector.org as of January 3, 2015 will not receive renewal letters. If they were found eligible for MassHealth, they will be subject to renewals next year.
50th Anniversary of Medicare and Medicaid Senator Ron Wyden, on behalf of 45 fellow Senators, recently submitted to the Congressional record a resolution commemorating the 50th anniversary of the Medicare and Medicaid programs. The resolution states in part, “…as a result of President [Lyndon] Johnson's call to action and Congress' bipartisan initiative that created the Medicare program, 54,000,000 seniors and people with disabilities have access to guaranteed health care benefits.” The resolution also highlights 50 years of work in Congress to protect and improve the Medicare program for all current and future beneficiaries, and states that all future efforts should “build upon President Johnson’s vision ‘to assure the availability of and accessibility to the best healthcare to all Americans, regardless of age or geography or economic status.’ ” Sen. Wyden reflects on the importance of Medicare and Medicaid and recalls why these programs were created. Fifty years ago less than half of older Americans had health insurance, and “many aging Americans without family to care for them ended up destitute, without necessary health care, or on the street.” Sen. Wyden concludes, “…that despite sharp differences and partisanship, the Congress of Johnson's day was able to rise above that culture and those challenges to find agreement and make America a much better place. As this new Congress begins, I hope we can use that 50-year-old spirit to strengthen, protect and improve Medicare and Medicaid to keep the guarantee strong and ensure health care to those who need it most.” -From Medicare Watch, Volume 6, Issue 2, Medicare Rights Center, January 15, 2015.
Patrick Signs the Unaccompanied Homeless Youth Act In the waning days of his administration, Governor Patrick signed the Unaccompanied Homeless Youth Bill into law. The Department of Elementary and Secondary Education estimates that over 4,000 high school students are experiencing homelessness and out on their own. Thousands more unaccompanied youth and young adults experiencing homelessness are not reflected in these numbers because they already have dropped out of school or are older and have finished school. Youth homelessness takes its toll on both the youth and our society at large. Youth who experience homelessness as adolescents often face bleak outcomes. While many youth are resilient and are able to overcome the ravages of homelessness, homelessness often leads to poor health outcomes including increased risk of death, exposure to violence, susceptibility to exploitation and high risk behaviors, and poor academic performance with increased risk of dropping out of school. This law seeks to reduce youth homelessness and its adverse effects by funding a continuum of housing and support services geared specifically for unaccompanied youth. What the Law Does Some key provisions of the law include:
More Information
-Adapted from the Bill fact sheet, Mass Coalition for the Homeless, updated 12/15/14.
Strict Shelter Rules for Homeless Families Draw Critics A mother and her year-old son spent their nights shuttling between a hospital emergency room and South Station after a friend kicked them out. Another woman, eight months pregnant, huddled overnight on a Quincy beach with her 3-year-old. Eventually, both families received spots in the state’s family emergency shelter system, Emergency Assistance (EA), but only after proving they had stayed somewhere that posed a health or safety risk, such as a car or an unheated basement. Their predicaments were the result of tightened eligibility requirements that homeless advocates say are making the process of getting shelter more complex, even dangerous. Housing lawyers say they are overwhelmed with families who have been denied shelter since the regulations went into place a few years ago. Hospital emergency rooms report an increase in the number of people showing up with nowhere else to go. “It’s just making it a more complicated process to get into shelter rather than reducing the number of families that are coming in or ensuring families are safe,” said Libby Hayes, executive director of Homes For Families, a Boston homeless advocacy group. Massachusetts is the only state in the nation with a “right to shelter” law guaranteeing emergency housing for homeless families that qualify — and the only state with its own shelter system, which includes complexes with shared bathrooms and kitchens, apartments, and motel rooms. But as the number of people who can’t afford to keep a roof over their heads keeps increasing, those who work to find them housing worry that help isn’t coming quickly enough. Some even call the “right” to shelter a myth. The Legislature redefined shelter eligibility requirements in 2012 in an attempt to better assess the needs and direct more resources into prevention and permanent housing. State reports show that since then, more than 2,000 families that might have been eligible under the old rules have been denied shelter annually. The first qualification for residents seeking shelter is that their income must be less than 115 percent of the federal poverty level — or just under $1,900 a month for a family of three. Those over the income limit are referred to shelters run by groups such as FamilyAid Boston, which reports demand has doubled in the past year. Families now also have to show they are homeless for one of four reasons: domestic violence, natural disaster, no-fault eviction, or health and safety risks. Most fall into the last — and most contentious — category, which includes families that have bounced around from place to place over a short period of time, and those staying somewhere unfit for habitation. Homeless advocacy groups have tried in vain for several years to get an “imminent risk” category added to the eligibility rules, to keep families from becoming homeless before they are given a bed. The state disputes that more people are being turned away, pointing out the monthly acceptance rate, about half, is roughly the same as it was before the new categories were added. Families are not required to prove that they are living in an unsafe situation before they are given a place to live, said Aaron Gornstein, who ran the Department of Housing and Community Development until he was replaced earlier this month by Governor Charlie Baker. “We do everything possible to avoid that situation,” said Gornstein, noting the state has added 1,000 shelter beds in the past 18 months and recently started a program to immediately connect families seeking shelter with housing services. “The focus should be on homeless prevention and more permanent affordable housing.” Baker has said solving family homelessness is a top priority, but his administration declined to discuss shelter admission rules. Some blame the disconnect between needs and eligibility rules on overzealous state workers. Others suggest advocates are advising families to sleep in their cars or in emergency rooms so they can get placement. As many as 15 families a month go to the pediatric emergency room at Boston Medical Center seeking a place to sleep — a rare occurrence a few years ago — and many reported they were sent there by state workers, said Megan Sandel, a pediatrician and researcher at the South End hospital. ER staff are required to assess each child who comes in, billing Medicaid for any tests or care provided, and families are given a room for the night, taking up valuable resources, Sandel said. They are discharged with a diagnosis of “homelessness,” which is their ticket to getting shelter. Advocates maintain there is no need for such strict regulations. Shelters are a last resort, said Robyn Frost, executive director of the Massachusetts Coalition for the Homeless, one of the nonprofits pushing for shelter reform. “Most people aren’t going to drag their kids to an emergency room in the middle of the night if they have somewhere else to go,” she said. -See the full Boston Globe article.
Medicare Increasingly Rewarding Quality of Care Through Provider Payment Models This week, the Department of Health and Human Services (HHS) outlined its goal to revamp the current Medicare models for paying doctors and hospitals. A fact sheet released by the Centers for Medicare & Medicaid Services details how the government hopes to improve payments to providers by rewarding high-value, well-coordinated care instead of high-volume care. Beginning in 2016, Medicare will tie 30 percent of all payments to providers in the traditional Medicare program to models that prioritize the quality of care provided. By 2018, HHS hopes to increase this to 80 percent. Ultimately, HHS hopes to move entirely to a payment system that compensates on the basis of the health and well-being of patients, rather than the amount and type of services performed by health care providers.
Read the CMS fact sheet. -From: Medicare Watch, Volume 6, Issue 4, The Medicare Rights Center, January 29, 2015.
Medicare Advantage- Members of Congress Advocate to Ensure Network Protections In December, a bi-partisan group of U.S. Senators and Representatives wrote to the Centers for Medicare and Medicaid Services (CMS), asking the Agency to take steps to protect Medicare beneficiaries whose Medicare Advantage (MA) plans make significant changes to their provider networks mid-year. As reported across the country in 2013 and 2014, mid-year changes to MA plan networks became more commonplace, meaning that physicians and other health care providers were dropped from plan networks outside of Medicare’s annual enrollment period. The fall open enrollment period is typically the only time Medicare beneficiaries enrolled in a particular MA plan can change to a different plan or move to Original Medicare for the upcoming year. Unless an individual qualifies for a Special Enrollment Period (SEP) to change his or her Medicare coverage outside of the open enrollment period, he or she may have to wait until the following year to make changes – long after changes to MA insurance carriers' networks take effect. To address this issue, the members of Congress ask CMS take a number of steps to protect beneficiaries. Specifically, the letter asks that CMS:
-From Medicare Watch, Volume 6, Issue 1, The Medicare Rights Center, January 8, 2015.
Mass Workfare Participation Fell Sharply and Work Incentive Best Practices Massachusetts has the nation’s lowest participation of welfare recipients working to receive their benefits, undermining one of the key reforms that was intended to move people from public assistance to self-sufficiency, according to a study to be released this month by a conservative Beacon Hill think tank. Only 7.3 percent of people receiving welfare benefits in the state held jobs in fiscal 2011, the most recent year for which data were available, according to the Pioneer Institute. That’s roughly one-fourth the national average of about 30 percent. Under the state- and federally-funded welfare program, known as Temporary Assistance for Needy Families (or TAFDC in Massachusetts), eligible recipients are required to work 20 to 30 hours a week or perform community service to receive benefits, which average about $453 a month. Roughly 160,000 people in Massachusetts currently receive benefits, but people who are physically unable to work, mothers of young children, and others are exempt from the work requirement. In Massachusetts, participation in what’s known as workfare — which includes jobs, community service, and job training — fell from 22 percent of recipients in 2010, even as national participation rose, the study says. “Our state has taken its eye off the prize with regard to workfare,” said Greg Sullivan, research director at Pioneer and coauthor of the report. “It seems Massachusetts has effectively abandoned the idea.” Sullivan, a former state inspector general, criticized Deval Patrick for “gutting” the work requirement when he was governor. “We were really the only state that had that kind of drop,” Sullivan said. The report used data from the US Department of Health and Human Services for fiscal 2011, which ended June 2011, and found that Massachusetts was the only state with a workfare participation rate below 10 percent. Connecticut’s rate was 59 percent, New Hampshire’s 49 percent, and Maine’s 19 percent. Rhode Island, which ranked just above Massachusetts, had an 11 percent rate. Massachusetts’ rate declined as the economy improved, according to the study. Participation during the Patrick administration peaked at 47.5 percent in the recession year of 2009, when unemployment climbed to nearly 9 percent statewide. In 2011, the jobless rate averaged about 7 percent. (The unemployment rate is currently less than 6 percent in the state). According to Sullivan, the state was able to sidestep the work requirement because the federal government offers caseload reduction credits to states that shrink their welfare rolls; the credits can offset workfare participation requirements. The state’s success in reducing welfare caseloads allowed workfare participation rates to decline without incurring federal penalties, Sullivan said. He called on Governor Charlie Baker to “resuscitate the workfare program.” Baker was an architect of welfare reforms in the administration of Governor William Weld in the 1990s. The state’s workfare plan became a model for national welfare reform enacted during the administration of President Bill Clinton. “A major reason for the low work participation rate is the shockingly low amount Massachusetts spends on programs and work supports,” said Deborah Harris, a staff attorney at the Massachusetts Law Reform Institute, a nonprofit poverty law center in Boston. In case you think Harris is making excuses for people who are too lazy to find a job, the Pioneer Institute’s Charles D. Chieppo agrees with her analysis. “Success of the [workfare] program is dependent on getting the private sector to participate,” said Chieppo, who coauthored the welfare report with Gregory W. Sullivan. “When the [work support] money is cut, that becomes much harder to do.” Massachusetts devotes roughly 1 percent of all federal and state money that’s allocated for welfare benefits to job training and other work support programs. That’s also a lower percentage than any other state. If only 7.3 percent of welfare recipients are working, what about the 92.7 percent who aren’t? Many can’t. Indeed, they tend to be the neediest, explained Harris. They have severe disabilities, cognitive impairments, and limited English proficiency. Their lives are in crisis. They may be homeless. In short, it’s harder to put them on a path to independence, no matter how much funding is allocated for training. They truly need the safety net provided by public assistance. Best Practices The 1996 federal welfare reform law is discouraging states and localities from experimenting with some of the most promising ideas for getting people back to work, according to a recent report by the U.S. Government Accountability Office (GAO). The independent auditing arm of Congress found that incentives baked into the nation's largest cash assistance program -- Temporary Assistance for Needy Families (TANF)-- actually undermine efforts to employ the poor. The problem, according to the report, is that the current system encourages states to focus on activities that help them meet a flawed federal performance measure: the work participation rate. The measure, said Elizabeth Lower-Basch, a welfare policy analyst at the Center on Law and Social Policy, doesn't reflect how many people on TANF are working, or even doing the things most likely to lead to work. "It's a process measure," she says. "It doesn't look at whether people get jobs." Instead, the participation rate requires states to make sure that at least half of eligible TANF families participate in one or more prescribed activities -- such as searching for work or job training -- for a certain number of hours per month. The report also notes that the measure adversely encourages TANF agencies to concentrate on job-ready participants or participants that might not need as much help as "hard-to-employ" participants who have health problems, disabilities, criminal records, dependence on drugs, limited education or a responsibility to care for a disabled relative. In either case, states appear to be meeting the letter of the law, but not its intent. To better promote innovative, research-driven employment approaches, the GAO report points to four evidence-based strategies, detailed below, being implemented in 10 places around the country: subsidized employment, treatment coupled with employment services, career pathways and modified work first. With subsidized employment, public funds create or support temporary work for someone who would otherwise be unemployed. One example is the San Francisco Jobs Now! program, which gradually reduces its contribution to a participant's wage over five months. Public funds cover 100 percent of wages in the first month, 75 percent in the second month and $1,000 per month for the next three months. Employers have to agree to try to retain the participant once the subsidy runs out. San Francisco administrators told the GAO that the employee retention rate is between 75 percent and 80 percent. Subsidized employment strategies are also being tried in Los Angeles, Erie County, N.Y., and Kentucky. Under treatment and employment services, officials try to address barriers to employment, such as mental health needs, substance abuse or a physical disability, while helping people look for work. Utah's Licensed Clinical Therapist Program still assists people with job searches and resume building, but also offers a clinical assessment of mental health problems and clinical therapy sessions. These services are also offered in New York City and Ramsey County, Minn. Under the career pathways model, TANF participants receive basic education while also learning skills needed for a specific job and industry, usually with guidance from local employers. In Washington state, 34 community and technical colleges train people in classrooms for careers with a demonstrated market demand in the region, such as health care, early childhood education and advanced manufacturing. Kentucky and Minnesota are also experimenting with career pathways models. "Work first" refers to mandatory work-related activities, such as job searching, rather than education and training that might lead to a job later on. The district's modified work-first program differentiates people who are ready for a job and those who need to upgrade their skills, experience or education before looking for work. Despite the fact that research suggests the highlighted approaches might be some of the best ideas today for helping the poor get jobs, administrators in three of the jurisdictions said it would be difficult to secure state funding for their programs -- in light of other demands for the same money - if they started today. The GAO authors concluded that it is unlikely the lessons learned from these programs will be widely adopted until Congress changes the law that created TANF. Sources and for More Information
Highest Income MA Residents Pay Lowest Share of Taxes A new study released this month by the Institute on Taxation and Economic Policy (ITEP) finds that the highest income taxpayers in Massachusetts, and across the country, pay a smaller share of their income in state and local taxes than do low and middle income taxpayers. The study, Who Pays?, analyzes tax systems in all 50 states and factors in all major state and local taxes, including personal and corporate income taxes, property taxes, sales and other excise taxes. Taxes, of course, are how we pay for our schools, our roads, our parks and playgrounds, public safety, our safety net, and everything else we do together through our government to make life better for all of our families and all of our communities. The ITEP study also points out that the Massachusetts tax system has grown more regressive over the course of the past decade. The overall tax burden for low-income families has actually increased slightly since 1989, while the total tax burden for the most affluent of Massachusetts’ families has declined by more than a percentage point. To provide more detail on the situation in Massachusetts, MassBudget also published updates of two factsheets: Examining Tax Fairness and Where Does the Taxachusetts Label Come From? They note that in the 1970s the Taxachusetts label may have been warranted, but that the state is now in the middle of the pack when compared to the rest of the country. In examining the Massachusetts tax system they found that the highest income 1% of taxpayers pay $83,000 a year less than they would if they paid the same percentage as most other taxpayers. This costs the state $2.1 billion a year. New study--Who pays lowest taxes in MA?, e-mail from MassBudget.org, January 14, 2015 and http://www.massbudget.org/reports/pdf/whopayspress.pdf.
Distinguishing Grief, Complicated Grief, and Depression Editor's Note: Medscape contributor Ronald W. Pies, MD, professor of psychiatry at SUNY Upstate Medical University in Syracuse, New York, recently moderated an email discussion between lead author M. Katherine Shear, MD, program director for Columbia University's Center for Complicated Grief, and Sidney Zisook, MD, distinguished professor and director, Department of Psychiatry at the University of California San Diego, La Jolla, California, on what complicated grief is, how to treat it, and how to distinguish it from grief and depression. Depression vs Grief vs Complicated Grief Dr Zisook: If a person meets criteria for one of the clinical conditions, but it is a first episode and relatively mild (eg, only five or six symptoms are met and these do not include feelings of worthlessness or suicidal ideation), brief (less than 1 or 2 months) and only minimally impairing, it may make sense to delay making a formal or definitive diagnosis while more information is gathered and a tincture of time is allowed its due. Just as it is important not to overdiagnose the blues of everyday life as major depression, it is every bit as vital not to overlook major depression when it is there. No disorder is more painful or has a more profound effect on the way a person relates to others, feels about themselves or their worth as a human being, functions in everyday activities, or maintains hope of a better future. Sometimes major depression seems to occur out of the blue, with no warning; sometimes its onset is gradual and almost unnoticeable; and sometimes it seems to be brought on, or intensified, by stressful life events, such as the death of a loved one. When that happens, a reverberating cycle sets in: The depression increases the stress, intensifies the grief, and may even interfere with grief's resolution, setting the stage for a condition we call "complicated grief." I would rephrase the question I was asked to discuss. The more meaningful question is not so much, "How can grief and MDD be differentiated?" as it is, "How can an MDE be diagnosed when it occurs in a recently bereaved person who is still actively grieving?" That can be a challenging and tricky clinical conundrum, even for the most experienced clinician. The DSM-5 does a good job in helping clinicians to understand when grief may be complicated by a co-occurring MDE. In the footnote for the diagnostic criteria of an MDD, the DSM-5 notes:
Even with these guidelines, is not always easy to diagnose an MDE in the context of bereavement. It is clear that a symptom checklist is not enough. Rather, a more nuanced assessment, taking into account some of the features and phenomenology noted above, combined with the unique history, beliefs, and social/cultural dimensions of the person and their environment, must be weighed into the diagnostic process. Sometimes it is useful to wait before making a definitive diagnosis. This is especially true in someone who does not have a previous history of MDD, and if symptoms are relatively mild and not life-threatening. When in doubt, past history and family history, as well as a tincture of time, may help inform clinical judgment and Dr Shear: Complicated grief is at the high end of the grief spectrum in both intensity and duration. People with complicated grief are often caught up in ruminations, avoidance, or maladaptive proximity-seeking. Complicated grief ruminations are usually focused on counterfactual accounts of the death—for example, "If only I had made him go to the doctor sooner" or "If only I had not left the room right before she died." Depressive rumination is different. Depressed people get caught up in thoughts about being worthless or being a bad person or thoughts that nothing good ever happens in the world, etc. With depression, people may become withdrawn and not want to go out or socialize. With complicated grief, avoidance is more specific, focused on not wanting to confront reminders of the person who died. People with complicated grief are desperate to feel close to their deceased loved one and may spend hours looking at photos, touching or smelling their clothes, or daydreaming about times they were together. These times are usually pleasurable until the person "wakes up" and remembers that the person is gone. -See the full Medscape.com article.
Tool May Help Detect, Monitor Aging Symptoms A new tool may provide a simple and reliable way to detect and monitor cognitive, functional, and psychological symptoms in aging adults, according to the tool's developers, who are from the Regenstrief Institute and Indiana University Center for Aging Research, in Indianapolis. The Healthy Aging Brain Care (HABC) Monitor "helps busy physicians accurately measure and monitor the severity of symptoms, providing valuable information that the patient's entire care team needs," Malaz Boustani, MD, MPH, notes in a statement. "We have been using this tool in the Eskenazi Health System for more than 2 years," Dr Boustani, medical director of the Eskenazi Health Healthy Aging Brain Center, in Indianapolis, told Medscape Medical News. "We use it every time the patient comes to the clinic, just like you'd take a patient's blood pressure at every visit. I can compare it with the last visit, and I have a dashboard to track the numbers and decide if my care plan is working or if I should make modifications," he said. Quick and Easy The HABC Monitor includes 27 items on a 4-point scale to assess cognitive, functional, and psychological symptoms. There are self-report and caregiver versions, which can be completed online or with paper and pencil in 2 to 3 minutes. The tool asks caregivers and patients questions such as, during the past 2 weeks, how often have you (or your loved one) had problems with the following:
Beneficial Concept Commenting for Medscape Medical News, Keith Fargo, PhD, director of scientific programs and outreach at the Alzheimer's Association, said, "This research is about early and accurate detection and cognitive assessment, and the Alzheimer's Association is supportive of ongoing research in that area. This concept of ongoing assessment and evaluation of a person's cognitive state is a beneficial concept, and there is a need for this kind of tool [to be] used under the supervision of a healthcare professional." Dr Fargo noted that the Alzheimer's Association "for several years now has been making efforts toward having cognitive assessment included, for example, in the Medicare annual wellness visit, because we do think it's important for physicians to have a baseline on all of their patients and then be able to track that over time to see whether there is a deviation from that baseline so they can intervene as early as possible." -See the full Medscape article.
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