Highlights

• 2015 FPLs
• New Assisted Living Rules
• Transgender Shelter Rights
• Many Exhaust Fuel Assist
• ABLE Accounts- More Detail
• Free Tax Prep
• Lodging & Support: ROFEH
• Neighbor Brigade
• MassHealth Gender Dysphoria Coverage

Sections

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

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

MassResources.org Ceasing Operation

We are sad to report that we’ve  been informed that as of March 1 Massresources.org will cease operations. (Though at press time the site is still operational.) The reported cause is an unsustainable business model. The site had always been free to users. A couple of years ago they moved to a partial pay-wall, asking professional and organizational users to support the site via subscriptions. Those revenues proved insufficient.

Many of you are regular users of the site which offered detailed explanations of and advocacy tips for public benefits and community resources in remarkably easy to understand language in an easy to navigate environment. It was also the Community Resource Center’s “go to” resource.

We will be working to find or create alternate content for the roughly 200 links to their site from the staff access area of our website. We apologize for the inconvenience during this process. Social Service staff can contact their designated resource specialist for assistance with benefit or resource information. Please feel free to contact Ellen Forman if you find broken links or if there are pages you think we should prioritize.

2015 Federal Poverty Levels

The Federal Poverty Levels (or Guidelines – FPLs or FPGs) are updated each year and are used to determine income-eligibility for certain public benefits programs. They are announced each January in the Federal Register and then adopted for use by the specific benefit programs at various times during the year.

New MassHealth upper income limits go into effect March 1. Massachusetts Law Reform Institute typically creates an easy to read grid that allows one to check for income-eligibility for all MassHealth coverage types. The grid should be posted on the Mass. Legal Services website in the coming days.

Because open enrollment for ConnectorCare and Qualified Health Plans begins before the announcement of the next year’s guidelines, the previous year’s (2014) are used.

WIC 2014 income guidelines remain in effect until July 1.

The Massachusetts Senate and House this month passed identical bills that tweaked Governor Baker’s plan to address a mid-year budget gap. The bills were very similar to the Governor’s original proposal. The only substantive differences to Baker's plan were that the Legislature's bills restored $12 million in spending to sheriffs and public defenders, since those accounts are running deficits, and they eliminated language that would have given Baker authority to unilaterally restructure MassHealth benefits.

Baker administration officials did not publicize how they planned to use the authority they asked for in the bill. But Al Norman, executive director of Mass Home Care said administration officials told them in a Feb. 4 conference call that they planned to save the state $6 million by raising the bar on how disabled a person must be to qualify for a personal care attendant or for adult foster care programs. Eligibility for those programs is determined by how many tasks of daily living a person needs help with, and the administration wanted to increase the number of daily tasks required to get into the programs.

Secretary of Health and Human Services Marylou Sudders told advocates that Baker would not resurrect the plan in 2015 or in the budget for 2016. In separate remarks, Sudders said that she wants to have a "sustainable" Medicaid program by fiscal year 2017. She suggested that the administration will look at how to change service delivery, for example by moving away from a fee-for-service model and toward a model where insurers are paid to keep a population of people healthy.

Under the plan, the administration is not cutting the Department of Children and Families or homelessness services. Norman praised the administration for not cutting funding for elderly home care, which he said often happens when budgets are tight.

Cuts included in the proposal include reductions in funding for grant programs for Head Start and gang prevention — but, the administration says, the cuts of about $1 million each do not affect grant money already promised or doled out.

Some cuts appear at odds with areas Baker has said are priorities. For example, Baker has pledged to tackle the state’s opiate addiction crisis, but he is cutting $5 million for substance abuse counselors. Administration officials say that specific program was never implemented, so there is no reduction in the number of current counselors. They insist that Baker’s plan protects other substance abuse programs.

Sources and for More Information

• Massachusetts Senate reluctantly passes Gov. Charlie Baker's transportation funding cuts, masslive.com
• Baker administration will not revive proposed changes to MassHealth disability programs, masslive.com
• House OK’s budget-cutting bill that tweaks Baker’s plan, The Boston Globe

New Rules to Let Frail Elders Stay in Assisted Living

Frail elderly residents will still be allowed to live in assisted living facilities under hotly contested rules unveiled this month by Massachusetts regulators. The regulations, aimed at strengthening protections for some of the state’s most vulnerable residents, mandate expanded training for facility workers and require detailed emergency evacuation plans, including enough equipment and medicine if extreme weather threatens.

But regulators backed off one of the most closely watched provisions which would have prohibited assisted living facilities from accepting residents, or allowing them to remain there, if residents require more than 90 consecutive days of skilled nursing care. (See New Proposed Assisted Living Rules Proving Controversial, MGH Community News, December 2014)

Many elders who once would have moved to a nursing home when their health declined are instead choosing to remain in assisted living, often because it costs significantly less than nursing homes. Over time, the population in these loosely regulated, apartment-like facilities has grown increasingly frail. About 14,000 people in Massachusetts live in about 225 of these facilities.

Elder advocates had lobbied for updated rules, saying the guidelines to protect residents had not kept pace and had not been updated since 2006. The state’s assisted living law, written in 1994, included a prohibition on frail residents who required months of skilled nursing care, but the state never took the last step to ensure the law would be enforced, by including it in regulations.

Industry officials quoted in a Globe story last fall suggested that rule had not been widely enforced. Instead, they said, residents requiring skilled nursing have been allowed to stay in assisted living and hire private nurses. Shortly after that story appeared, the Executive Office of Elder Affairs, which is charged with overseeing the facilities, included the prohibition in proposed new regulations.

The action infuriated industry leaders, who packed a December public hearing, and said enforcing such a rule would be traumatic for frail elders, and would require administrators to evict residents from facilities that had become their home.

Some attorneys who specialize in elder abuse cases said they believe insufficient training and staffing are at the heart of most of the abuse cases they see in assisted living residences. The new rules mandate additional education in two areas of special concern raised by advocates: recognizing and reporting elder abuse, and techniques for managing and calming aggressive behavior, something commonly encountered in caring for patients with dementia.

But the rules stopped short of requiring some measures advocates had long sought, including minimum staffing levels for all assisted living residences. Instead, the rules stipulate only that it “shall never be considered sufficient to have less than two staff members in a Special Care Residence,” which typically cater to residents with dementia.

James Wessler, president of the Alzheimer’s Association of Massachusetts and New Hampshire, said in a statement that the organization is pleased to see the new rules enacted but felt that some critical issues remain. The association had urged regulators to beef up rules regarding activities, saying they significantly improve the quality of residents’ lives, especially for those with dementia.

-See the full Boston Globe article.

Transgender Rights in Homeless Shelters- Model Document

In a presentation at the January Massachusetts Coalition for the Homeless meeting,  GLAD (Gay & Lesbian Advocates & Defenders) Staff Attorney Allison Wright discussed a gender identity non-discrimination policy formed with Lynn Emergency Shelter. GLAD hopes this policy will serve as a model for other homeless shelters.

GLAD believes transgender people accessing shelter have the right to:

• Access shelter services free of discrimination and harassment
• Shelters should not turn away transgender people presenting for intake because of their transgender status, the length or extent of their gender transition, and/or because they do not meet the expectations of what a man or woman is supposed to look like. All incidents of harassment—by fellow clients or by staff—should be documented in writing.
• Access restrooms, showers, dormitories, and other facilities consistent with their gender identity
• Use and be referred to by names and pronouns consistent with their gender identity
• Express themselves by wearing gender affirming clothing
• Keep their transgender status and medical history private
• All assertions by clients of their gender identity should be presumed accurate and should not be questioned by staff without a credible, objective, demonstrable basis.
• Request accommodations for their safety and privacy
• Any shelter client (transgender or not) with safety or privacy concerns should have the right to request alternative accommodations when available. The use of private rooms should not be reserved for transgender individuals only, and the unavailability of alternative space should not be a basis for altering a transgender client’s accommodations.

GLAD urges those who feel that they are not being treated with respect and dignity when accessing shelter services to contact its LGBTQ and HIV legal rights resource infoline, GLAD Answers. GLAD Answers is a free and confidential service that provides information, assistance, and referrals, and helps locate private practice attorneys sensitive to the needs of the LGBT community. . Occasionally, some lawyers are willing to take cases pro bono or on a contingency basis.

GLAD Answers is available by phone and live chat Monday through Friday from 1:30 – 4:30 PM; call 800-455-GLAD or chat live at http://www.gladanswers.org/. E-mails sent to GLADAnswers@glad.org at any time will be returned by the next business day.

GLAD is an organization dedicated to ending discrimination based on gender identity/expression, HIV status, and sexual orientation through services such as strategic litigation, public policy advocacy, and education. For cases outside of New England, GLAD will refer to national organizations as laws related to sexual orientation, gender identity, and HIV/AIDS status  vary by state.

To access GLAD’s online resources and publications, see www.glad.org or call 617-426-1350.

- Information adapted from GLAD Staff Attorney Allison Wright’s presentation at the January 30, 2015  Massachusetts Coalition  for the Homeless meeting.

Families Exhausting Heating Assistance in Boston Area

Early in February Action for Boston Community Development (ABCD), a nonprofit social service provider, said 18,000 families it served had exhausted their federal heating assistance benefits and appealed to the state for help.

The group said it is still taking new applications, but many of its families have already hit their limit for heating aid. For a family of four living below the poverty line, that breaks out to $1,025. ABCD blamed cold temperatures and record-high electricity costs for the shortage.

ABCD serves Boston, Brookline, Newton, and seven other cities and towns to the north of Boston.

Near the end of the month Action for Boston Community Development reiterated its call for the state to allocate $20 million for emergency heating assistance. That request comes at a bad time, however, with the state Legislature and governor trying to cut spending to close a $768 million hole in the budget. On February 23rd, US Senators Elizabeth Warren and Edward Markey joined the effort, requesting the federal government allocate an additional $6 million to Massachusetts as part of the national Low-Income Home Energy Assistance Program. So far, the state has received about $144 million, and the money requested by the senators is normally used for discretionary and administrative expenses. At the State House, legislators and the governor have said they’re committed to helping the state’s poorest households.

-See the full Boston Globe articles.

• Heating assistance money exhausted in Boston area
• Community groups seek more heating aid

ABLE Accounts – Additional Details and Comparison to Third Party Special Needs Trusts

As reported last month (ABLE Act Will Allow Certain SSI Recipients Additional Savings, MGH Community News, January 2015) on December 19, 2014, President Obama signed into law the Achieving a Better Life Experience (ABLE) Act, enabling parents of children with significant disabilities to set aside funds to help pay their children’s expenses, tax-free, and without affecting their eligibility for public benefits. It is set up like a 529 account for the costs of education. The special needs community has been advocating for this for years, and it certainly sounds like a victory. But reading the fine print, there are some significant limitations to these accounts.

These accounts are only available to individuals who became disabled before age 26, but if they qualify, funds may be contributed at any age. The account value, up to $100,000, will be disregarded in determining eligibility for Supplemental Security Income (SSI) and Medicaid. In other words, a person can have up to $100,000 in an ABLE Account and still be considered to have less than $2000 in assets, thereby qualifying for SSI and Medicaid. So, this can be simpler than creating a special needs trust. (However, note that payments from an ABLE account for housing reduces SSI payments in the same way as other payments for housing.)

From a parent’s perspective, there are three major problems with the ABLE account:

First, due to budget constraints, Congress limited the amount that can be contributed to an ABLE account to $14,000 a year, from any source – and each person can only have one ABLE account, total. A special needs trust probably will still be required if anyone may receive more than $14,000 in a year or $100,000 overall.

Second, if there is still money in the ABLE account when the child dies, the money goes to repay Medicaid – it cannot be left to another sibling, relative or organization. 

Third, the money in the account must used to pay for qualified distribution expenses, defined as “any expenses related to the eligible individual's blindness or disability . . . including: education, housing, transportation, employment training and support, assistive technology and personal support services, health, prevention and wellness, financial management and administrative services, legal fees, expenses for oversight and monitoring, funeral and burial expenses, and other expenses, which are approved by regulations.” This definition, although fairly broad, has limitations – for example, it does not include food, entertainment, or vacations .(It is not yet clear how these restrictions will be enforced.)

One benefit of the ABLE Act is that it allows the beneficiary of the account to control the account themselves, unlike a special needs trust.

Unfortunately the accounts cannot be opened just yet. The law states that qualified ABLE Programs must be established and maintained by the states, at the state’s option (similar to 529 accounts). In 2014, in anticipation on the passing of the ABLE Act, Massachusetts passed a law to set up such programs. But Massachusetts can’t get started until the federal regulations governing the accounts are finalized, which will take another few months. Massachusetts residents should be “able” to open ABLE accounts by early 2016, through the same brokerages that manage 529 accounts.

For those who are considering using an ABLE account in addition to or instead of a third-party supplemental needs trust, below is a chart comparing the two:

Comparing ABLE Accounts and Third Party Special Needs Trusts

Watch for more information from us on ABLE accounts as they open in Massachusetts.

-Adapted from and for more information see the full Margolis & Bloom blog post.

Earlier this month, a federal judge in Texas temporarily halted two controversial immigration initiatives that President Obama announced last year and planned to carry out starting this week. Across the nation, immigrants have flocked to information sessions and have gathered the records needed to apply.

US District Court Judge Andrew S. Hanen, in the border city of Brownsville, Texas, issued a temporary injunction against the programs on the Presidents’ Day holiday according to the court. He said the states fighting the immigration initiatives had the right to bring the case and that the Obama administration had failed to follow the proper procedure in carrying them out.

The ruling marked a preliminary victory for Texas, Maine, and 24 other states that had sued to stop the programs, saying they would create an unfair burden on them.

The injunction paralyzed Wednesday’s planned expansion of Obama’s Deferred Action for Childhood Arrivals program, which started in 2012, and grants temporary work permits and residency to illegal immigrants brought here as children. Wednesday’s expansion would have removed an age cap, allowing immigrants age 31 and older to apply. The judge’s ruling does not affect the existing program, known by its initials, DACA.

The judge also halted a second program, Deferred Action for Parents of Americans and Lawful Permanent Residents, which would grant work permits to parents of US citizens and green card holders starting in May.

The White House immediately vowed to appeal the judge’s order to the Fifth Circuit Court of Appeals, a panel of judges that could uphold the injunction or overturn it. But Hanen’s order forced the Obama administration to suspend the programs just days after Homeland Security Secretary Jeh Johnson had urged immigrants to apply.

Is a Probate Proceeding Always Required After Someone Dies?

Probate is a legal process by which an appointed individual -- usually a spouse or family member -- is given the power to identify and gather a deceased person's ("decedent's") assets, pay any debts or taxes the decedent owes, and eventually transfer any remaining assets to the people who will inherit them, either according to the terms of the decedent's will (if one exists) or according to Massachusetts law (if one does not).  In 2012, Massachusetts adopted the Uniform Probate Code (MUPC) in an effort to simplify the state's probate and estate administration process.  Below are some key points to keep in mind regarding the probate process:

1. Probate is only required where the decedent held assets in his or her name alone.  Assets owned jointly, such as real estate, or bank or investment accounts, transfer automatically to the surviving owner.  So, too, assets with a named beneficiary, like retirement plans or insurance policies, transfer automatically to that designated individual without the need for probate. Given these exceptions, there are many cases -- for example, when the first spouse in a marriage dies -- in which few, if any, assets must go through probate.

2. Small estates can be handled expeditiously through "voluntary administration." Expanding upon prior Massachusetts law, Section 3-1201 of the MUPC provides for streamlined processing in cases where an estate does have assets subject to probate, but those assets consist entirely of personal property valued at no more than $25,000 (excluding one car, of any value).  An interested party, such as a spouse or other close family member, can initiate this process, known as "voluntary administration," once thirty days have passed from the decedent’s death.  Voluntary administration can be used whether the decedent left a will or died intestate.  Upon the filing of certain required items, such as the will (if any), an inventory of assets, a list of heirs, and a death certificate, the interested party is appointed the voluntary personal representative and given the power to gather assets, pay debts, and distribute property.

3. Many larger estates will still qualify for a streamlined "informal" probate process.  Supervised by a magistrate rather than a judge, the so-called "informal" process under MUPC §3-301 allows an interested party to petition for appointment as personal representative as soon as seven days, but no more than three years, after the decedent's death.  There are no hearings in informal probate, and, assuming the petitioner's underlying paperwork is in order -- showing, among other things, proper notice to heirs, filing of the death certificate and production of the original will (if any) -- a magistrate can swiftly issue an order of appointment allowing the personal representative to begin administering the estate.  There are, however, situations in which the informal process may not be used, including problems with a will (for example, if one exists but cannot be located or its validity is in question), difficulty identifying or locating heirs, when the petitioner is a creditor, or when there are heirs requiring special judicial attention (such as unrepresented minors or incapacitated persons).  These cases would be handled under the so-called “formal” probate process, typically by a judge, involving one or more hearings before the court. See MUPC §3-401. 

For more information on the probate process in Massachusetts, see the Mass Court System’s Self-Help Center website. 

-Adapted from, and for more information see the Margolis and Bloom blog post.

Free Tax Return Preparation for Qualifying Taxpayers

The Volunteer Income Tax Assistance (VITA) program offers free tax help to people who generally make $53,000 or less, persons with disabilities, the elderly and limited English speaking taxpayers who need assistance in preparing their own tax returns. IRS-certified volunteers provide free basic income tax return preparation with electronic filing to qualified individuals.

In addition to VITA, the Tax Counseling for the Elderly (TCE) program offers free tax help for all taxpayers, particularly those who are 60 years of age and older, specializing in questions about pensions and retirement-related issues unique to seniors. The IRS-certified volunteers who provide tax counseling are often retired individuals associated with non-profit organizations that receive grants from the IRS.

Before going to a VITA or TCE site, see Publication 3676-B for services provided and check out the What to Bring page to ensure you have all the required documents and information our volunteers will need to help you. *Note: available services can vary at each site due to the availability of volunteers certified with the tax law expertise required for your return.

VITA and TCE sites are generally located at community and neighborhood centers, libraries, schools, shopping malls and other convenient locations across the country. To locate the nearest VITA or TCE site near you, use the VITA Locator Tool or call 800-906-9887.

A majority of the TCE sites are operated by the AARP Foundation’s Tax Aide program. To locate the nearest AARP TCE Tax-Aide site between January and April use the AARP Site Locator Tool or call 888-227-7669.

-From Free Tax Return Preparation for Qualifying Taxpayers, IRS.gov

Accommodations and Support for Patients Traveling for Medical Care- ROFEH International

ROFEH International provides local accommodations, kosher meals, babysitting, support, respite care and transportation to and from Boston’s hospitals and airport all at no charge to those stressed with illness and financial pressures who come to Boston for life saving medical treatment. The organization has 8 furnished apartments in Brookline and services are provided by a network of committed volunteers. ROFEH helps those in need from all walks of life.

ROFEH serves as many patients and families as they can given the limits of their capacity. Realistically, there is typically a long waiting list for the apartments, and due to the variable nature of medical illness, it can be challenging to precisely predict availability. They may, on a case-by-case basis be able to offer some of their additional services to those not staying in their apartments.

For more information or to refer:  http://www.rofehint.org or call the Boston Office:  617-566-1900.

-Thanks to Elizabeth Ryan and Andra Sobran for reminding us of this resource and to Michael Hirsh for his assistance with this article.

Neighbor Brigade

Neighbor Brigade transforms local communities into caring centers by mobilizing residents to provide free, temporary, non-medical support to those who are experiencing an unexpected emergency such as a critical illness, accident, or family tragedy. Neighbor Brigade services are immediate, free and available to all regardless of age, religious affiliation, or economic situation.

By engaging a "neighbors helping neighbors" model, community-specific chapter leaders, and an online volunteer management software platform, Neighbor Brigade supplements where immediate family and friends cannot "do it all" in meeting the daily household needs of those experiencing a sudden crisis.

Since incorporating in 2010, Neighbor Brigade has grown to 29 chapters, with new chapters on the way. Largely concentrated in Eastern Massachusetts they currently have a presence in the communities below. Please click on the town to visit their chapter page, to request assistance, join as a volunteer, or just learn more about the chapter.

-Thanks for Andra Sobran and Lauren Howard for alerting us that we should remind staff about this resource.

CMS Finalizes Key Beneficiary Protections in Medicare Advantage and Part D

On February 6, 2015, the Centers for Medicare & Medicaid Services (CMS) finalized Medicare Advantage (MA) and Part D regulations. Under the new provisions, which were first proposed in January 2014, MA and Part D prescription drug plans are affected in a number of ways. The final rule will take effect 30 days after publication.

One of the  recently finalized rules: Medicare Advantage Prescription Drug (MAPD) private health plans, which offer managed hospital (under Medicare Part A), medical (under Part B), and prescription drug benefits (under Part D) to their enrollees, must establish a process to ensure that prescription drugs which may be covered under either Medicare Part A or Part B, or under Part D, are properly processed and approved for coverage by the plan. The Medicare Rights Center regularly receives calls to its national helpline from beneficiaries enrolled in MAPD plans whose plans deny coverage for a medication under Part D because it was coverable under another part, and whose plans did not then authorize or provide a process to authorize coverage for that same medication under the MAPD plan’s Part A or Part B benefit. Under the new rules, MAPD plans are directed to resolve these issues with little or no beneficiary involvement.

Read the CMS press release.

-Adapted from Medicare Watch, Volume 6, Issue 6, Medicare Rights Center, February 12, 2015 and the CMS press release.

MassHealth Releases Regulations for Coverage of Gender Dysphoria

In June 2014 Massachusetts became the third state in the nation (behind California and Vermont) to allow coverage of transgender medical services, including gender reassignment surgery, as a standard benefit under MassHealth. New MassHealth regulations, effective January 2, 2015 have implemented the change, now allowing coverage of treatment of gender dysphoria, including gender reassignment surgeries and hormone therapies.

Gender reassignment surgeries and certain hormone therapies require prior authorization. Providers should review the Guidelines for Medical Necessity Determination for Gender Reassignment Surgery, available at www.mass.gov/masshealth/guidelines, and the MassHealth Drug List, available at https://masshealthdruglist.ehs.state.ma.us/MHDL, for more information
on prior authorization requirements.

-See the MassHealth Transmittal Letters.

Medicare to Cover Low Dose Computed Tomography

The Centers for Medicare & Medicaid Services recently announced that Medicare will now cover screenings for lung cancer using Low Dose Computed Tomography (LDCT). This service will be covered once per year for Medicare beneficiaries who:

• are between ages 55 and 77, and are current smokers or have quit smoking in the last 15 years;
• have a history of smoking tobacco equivalent to 30 “pack years” - defined as one pack a day for 30 years; and
• have a written order from their doctor or qualified non-physician practitioner that meets certain requirements.

Read the CMS announcement.

-From Medicare Watch, Volume 6, Issue 6, The Medicare Rights Center, February 12, 2015.

Connector Tax Reporting Information

As you may recall the Affordable Care Act uses the tax system to provide subsidies to eligible people. Also under its individual mandate provisions most people are required to have health insurance or face tax penalties. This is the first tax-filing season since these provisions were fully implemented. There are two forms that those receiving coverage through the Connector or MassHealth may need for tax-filing purposes. At the end of January, the Health Connector and MassHealth mailed these tax reporting forms to certain members  enrolled in health insurance coverage during 2014. This is primarily pertinent to those with incomes above 150% FPL. Those with income above that amount should watch their mail for these forms and requests them if not received.

Form 1099-HC is a tax document that health insurance companies send members to let them know if their health plan meets the state's Minimum Creditable Coverage (MCC) requirements for the purposes of satisfying the individual mandate. The 1099-HC includes information needed to complete Schedule HC of the state income tax return.  Note that MassHealth and Commonwealth Care members with income below 150% FPL do not receive a 1099-HC unless they request one, as they are not subject to tax penalties based on their income. Other Massachusetts residents who are not enrolled in Commonwealth Care or MassHealth will receive their Form MA 1099-HC from their insurance carrier or plan sponsor.

Form 1095-A is a tax document that reports non-group health insurance policies purchased through the Health Connector in the previous calendar year (2014). Tax filers and other relevant adults who purchased health insurance through the Health Connector will use information from this form to report coverage and claim or reconcile premium tax credits on their federal income tax return.

Consumers seeking a duplicate of their Commonwealth Care 1099-HC form or their Qualified Health Plan 1095-A form can call the Health Connector Customer Service Center. MassHealth members seeking a copy of their 1099-HC form should contact MassHealth Customer Service Center.

More Information

• See the Tax Reporting talking points for more information and samples from the Health Connector.
• Visit MAhealthconnector.org for helpful FAQs. 
• The MTF website to review the training presentation and recording from the December ACA Learning Series conference call titled:  Marketplace and MassHealth Coverage at Tax Time
• Visit the Massachusetts Department of Revenue's website for information about state filing

-Adapted from Update from the Health Connector and MassHealth - February 12, 2015, MA Health Care Training Forum and the Health Connector’s Tax Reporting talking points.

Officials Look into Long Health Connector Hotline Waits

The Massachusetts Health Connector will examine why its call center became so overwhelmed that more than half the callers during peak times hung up in frustration after being left on hold for too long. The call center’s performance was among the major areas targeted for improvement by Connector officials this month at the monthly meeting of the agency’s governing board, as the Connector prepared for the final enrollment push prior to the February 15 deadline.

Despite adding staff, with sometimes more than 700 on the job, the Connector’s call centers were afflicted with long wait times and high hang-up rates. From Nov. 15 to February 10, the average wait time was 11.4 minutes and one in five callers abandoned his or her call. On peak days, however, waits averaged 50 minutes, and 60 percent of callers hung up without being helped.

Maydad Cohen, the top official overseeing the rebuilding of the Connector website, said Connector authorities were surprised by both the number and duration of the calls. The Connector will analyze why people decided to call and explore ways to better help them online, he said.

“Putting 1,000 people on the phone is the answer, but who can afford it?” said Cohen, who is leaving his post March 6. On average, about 500 full-time workers were answering the phones, but that proved to be insufficient.

Even with a well-functioning website, said Ashley Hague, the Connector’s deputy executive director, “When it’s about health insurance, people have thousands of questions.”

Another improvement promised for the next enrollment season will involve streamlining the payment system, a source of confusion and frustration for many. Currently, people need to leave the Connector website after selecting insurance and log on to a different site to pay. The site did not provide confirmation when payments were received. In the future, the payment system is expected to be fully integrated with the Connector and function more like an online retailer.

From Nov. 15 to February 10, 237,741 people enrolled in MassHealth, and 100,918 selected and paid for a health plan through the Connector.

-See the full Boston Globe article.

Nursing Home Dementia Care Lacks Oversight- New Rules Inadequately Monitored

Massachusetts regulators appear to be falling short in ensuring that nursing homes follow rules designed to improve care for some of their most vulnerable patients, those with dementia, a Globe review shows.

Nursing homes have been notably slow to implement the improvements: Some have not completed the required staff training for dementia care that is required of all nursing homes and was supposed to be finished nearly three months ago, the Globe found in a random check of about one dozen facilities. Meanwhile, at least 40 nursing homes have asked for waivers to complete other upgrades required for facilities that specifically advertise special care for dementia patients, according to state data. And six have been cited for their failures, the state said.

Despite the delays, state regulators are not conducting spot checks for compliance. They are, they say, already busy with routine monitoring of more than 400 nursing homes.

Instead, the state health department said in a statement that its inspectors will review dementia care during their annual visit to each facility, which means some nursing homes may not be checked for compliance for months.

The upgrading process has been slow nearly from the start; the department issued its dementia special care checklist for inspectors in December, nearly a year after the rules were adopted last February.

Arlene Germain, president of Massachusetts Advocates for Nursing Home Reform, said the new rules, once implemented, could substantially improve the lives of nursing home residents. But, she said, “strong oversight and greater nursing home participation are critical to ensure that the law’s benefits are meaningful and widespread.”

Nursing home administrators said they are struggling to comply with the rules because doing so is simply too costly.

Those rules, which are in addition to the more general training requirement, were designed to close a loophole that had allowed nursing homes to advertise dementia units without specific training for their workers, specialized activities for residents, or safety measures to prevent residents from wandering.

Massachusetts lagged behind much of the country on mandating such protections. A 2005 federal report noted that 44 states at that time already had requirements governing training, staffing, and security for facilities that provide specialized dementia care.

Under state rules, all licensed nursing homes, even those without a special dementia unit, were required by the end of November to complete dementia-specific training for workers who care for residents.

Regulators said it was important to mandate the training, because more than half of the state’s 41,000 nursing home residents have some form of dementia.

The additional rules that apply to facilities advertising specialized dementia care include hiring at least one “therapeutic activities director” dedicated to dementia residents to ensure they have meaningful and appropriate activities. The facilities must provide a large multipurpose room for group activities and family visits.

-See the full Boston Globe article.

The Overuse of Antipsychotic Drugs in Nursing Homes – Still a Problem

Many nursing homes are improperly prescribing antipsychotic drugs to patients even though federal law restricts their use. Almost 300,000 nursing home residents are currently receiving antipsychotic drugs normally used to treat bipolar disorder or schizophrenia and that are considered dangerous for patients with dementia.  

Why are these drugs being prescribed? Nursing home residents with dementia can often get agitated, anxious, or aggressive. In order to deal with these behaviors, nursing home employees may prescribe antipsychotic drugs, even though the drugs aren't approved by the U.S. Food and Drug Administration to treat symptoms of dementia. In fact, when it comes to dementia patients, the drugs have a black box warning, saying that they can increase the risk for heart failure, infections and death. In addition, federal law prevents the use of drugs as a way to restrain nursing home residents or for the sake of staff convenience.

Before a nursing home doctor prescribes antipsychotic drugs, the doctor is supposed to get the consent of the resident or his or her representative. The resident has the right to refuse the drugs and to ask for alternative treatment.

After a (May 2011) federal study found that 88 percent of prescriptions for antipsychotic drugs in nursing homes were being used to treat dementia, the federal Centers for Medicare and Medicaid Services (CMS) began a campaign to reduce use of these drugs. In two years, CMS was able to cut usage by 15 percent. However, National Public Radio (NPR) recently reported that the government is still not issuing serious fines for the misuse of antipsychotic drugs.

NPR's analysis of CMS data found that harsh penalties are almost never used when nursing home residents get unnecessary drugs of any kind. Inspectors grade these deficiencies according to the severity of the offense. And only 2 percent of the infractions were ranked at a level that might trigger a fine or worse.

But Dr. Patrick Conway, chief medical officer of the CMS, says that the government takes its regulatory and enforcement duties "incredibly seriously. It's the strongest lever we have." Conway's explanation: "There are many near misses, whether it's hospitals or nursing homes, where medication might be given that's not needed and doesn't cause permanent harm. We view that as a learning opportunity."

Conway points out that the initiative is ongoing. The agency's new goal for nursing homes is an additional 15 percent reduction in antipsychotic drug use by the end of 2016. But even if that goal is met, it will mean that after a five-year effort, almost a quarter of a million nursing home residents will still be getting largely unnecessary and potentially lethal antipsychotic drugs.

If you fear your loved one is being unlawfully prescribed antipsychotic drugs, contact your nursing home ombudsman or your attorney. 

The NPR story includes an online tool (scroll down to "Look Up Antipsychotic Medication Rates By Facility") that allows families to see the rate of antipsychotics use in the nursing facility in which a loved one resides.  

Sources and for More Information

• The Overuse of Antipsychotic Drugs in Nursing Homes, Margolis & Bloom
• Old And Overmedicated: The Real Drug Problem In Nursing Homes, NPR.org
• Nursing Homes Rarely Penalized For Oversedating Patients, NPR.org

Update on Vermont’s Drug Addiction Initiatives

In what many called an act of political courage, Gov. Peter Shumlin of Vermont devoted last year's annual State of the State address to what he termed a “crisis bubbling just beneath the surface that may be invisible to many.” A year later, Vermont has developed a reputation as the nation's most proactive state in the fight against drug addiction.

What sets Vermont apart is the scale of its effort to reorganize its health system as well as expand access to care and shift its criminal justice system toward treatment.

Rapidly expanding the availability of doctors who can treat opioid addiction and creating a better-coordinated system for patients got its start before Shumlin’s address, but much of the implementation took place this past year. Spending increased 40 percent with the help of a federal matching program that covers 90 percent of costs through two years to encourage states to create team-based approaches to patients with chronic conditions such as drug addiction.

To better coordinate care, the state is now divided into five geographic regions, each of which has a medical "hub" that assesses the severity of the problem, tests for related issues such as hepatitis C, provides methadone (a drug used to treat withdrawal) when warranted, works toward stabilizing patients, and connects patients to residential treatment or outpatient services. The state refers to those next-step services as “spokes.”

At the same time, the state is trying to shift reliance away from residential services toward family doctors, counselors and therapists to reduce hub waiting lists and provide more inpatient days to the people who need it most. There's required reviewing to determine whether patients still need residential services after 15 days  -- a tactic similarly used by at least 18 other states. If patients don't meet the standards, they continue treatment with a regular doctor. But Deb Richter, a primary care physician at a residential treatment center in Vermont, argues two weeks isn't enough time to help addicts avoid relapses, pointing to research that links longer residential stays with better outcomes.

The medical system changes are only one aspect of Vermont’s approach to drug addiction. The other reforms have focused on shifting the criminal justice system away from a punitive response to drug addiction. Some of the state’s ideas started elsewhere, but in several ways, Vermont has pushed them further, according to national analysts.

Take drug overdose immunity -- or “Good Samaritan” -- laws, for example. Twenty-two states have enacted some form of immunity law, which shields users and the people with them from arrest when calling 911 in the event of an overdose, according to the National Conference of State Legislatures. In most states, immunity only extends to possession and other low-level crimes, but Vermont’s law shields people from being charged with manufacturing or selling drugs when seeking medical assistance for an overdose.

And while many states are increasing the availability of the overdose-reversing drug naloxone, Vermont was the first state to allow pharmacies to sell it over the counter, according to Lindsay LaSalle, an attorney at the Drug Policy Alliance, which advocates for drug laws that focus on harm reduction instead of criminal penalties. 

 Additionally, over the last legislative session, Vermont passed a statewide system of mandatory pre-trial assessments that evaluate the risk of releasing a prisoner -- something only a handful of states have done system-wide. That system also allows judges to use that assessment to require treatment for drug offenders before they’re even charged, establishing drug addiction as a condition to avoid prosecution. The belief is that such policies can help people better maintain employment and stable lives. Allowing judges to take those measures without issuing a charge hasn’t been tried statewide, according to another analyst at the Drug Policy Alliance, and neither has a new program that maintains treatment for people in prison and while they transition out of prison.

-See the full Governing.com article.

Obama Budget Proposes Savings from Medicare, Medicaid

In his new budget, President Obama is proposing to squeeze $399 billion over the next 10 years out of Medicare, Medicaid, and other programs run by the Department of Health and Human Services.

Under the proposals, many Medicare beneficiaries would have to pay more for their care and coverage. The president would, for example, introduce a co-payment for new Medicare beneficiaries who receive home health care services, and he would collect $4 billion over 10 years by imposing a surcharge on premiums for new beneficiaries who buy generous private insurance to supplement Medicare.

In addition, Obama’s budget would reduce scheduled Medicare payments to teaching hospitals, nursing homes, and health maintenance organizations that care for older Americans and those with disabilities.

The budget would reduce the projected growth of Medicare payments for graduate medical education by $16 billion over 10 years while saving $116 billion in Medicare payments to drug companies for medicines prescribed for low-income patients. Obama would save more than $100 billion over 10 years by reducing inflation updates for providers that care for Medicare beneficiaries after they leave hospitals.

And he would cut $43 billion over 10 years from the projected growth of federal payments to Medicare managed-care plans, known as Medicare Advantage. The goal of this proposal, the White House said, is to “improve payment accuracy for Medicare Advantage.”

The president’s budget would collect $66 billion over 10 years by charging higher premiums to higher-income Medicare beneficiaries, for coverage of doctors’ services and prescription drugs.

Obama again proposes to ban deals between brand-name and prescription drug manufacturers that he says delay marketing of generic medicines. This, he said, would save Medicare and Medicaid more than $11 billion over 10 years.

-See the full Boston Globe article.

The Gut Microbiome and Diet: Focus on Depression

Purpose of review: With depressive disorders the leading source of disability globally, the identification of new targets for prevention and management is imperative. A rapidly emerging field of research suggests that the microbiome–gut–brain axis is of substantial relevance to mood and behaviour. Similarly, unhealthy diet has recently emerged as a significant correlate of and risk factor for depression. This review provides evidence for the gut microbiota as a key factor mediating the link between diet and depressive illness.

Recent findings: The development of new technologies is affording a better understanding of how diet influences gut microbiota composition and activity and how this may, in turn, influence depressive illness. New interventions are also suggesting the possible utility of pre and probiotic formulations and fermented food in influencing mental health.

Summary: Although in its early stages, the emerging field of research focused on the human microbiome suggests an important role for the gut microbiota in influencing brain development, behaviour and mood in humans. The recognition that the gut microbiota interacts bidirectionally with other environmental risk factors, such as diet and stress, suggests promise in the development of interventions targeting the gut microbiota for the prevention and treatment of common mental health disorders.

-See the full Medscape summary article.