Highlights

• Fuel Assist Starts Nov 1
• Connector Open Enrollment
• Elder Care Wait List Ending
• New Housing Protections for DV Survivors
• Nursing Home Regs Revised
• SNAP Advocacy Updates
• Foreclosed Homeowners Must File Form to Protect Rights
• Chelsea Soldiers' Home Concerns
• Boston Ofc of Housing Stability
• Camp Sunshine- Year-Round Retreat for Families of Ill Children
• MBHP Center for Hoarding Intervention
• Thanksgiving Meal Baskets

Sections

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

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

Voting for Persons with Disabilities and Inpatients

Voting - Inpatients

As reported last month (Voting- Absentee Ballots, Early Voting and Last-Minute Requests, MGH Community News), during each presidential election season the Community Resource Center fields questions about how inpatients can vote.

• If the patient has family- a family member can apply for an absentee ballot on their behalf (see article for links). The deadline to apply is the day before the election. The ballot must then be completed by the patient and returned to the local election office by 8:00 pm on election day.
• If there is no family to apply for and deliver the ballot and the patient has entered the hospital after noon on the 5th day before the election - they should contact their local city or town clerk for instructions.

Voting - People with Disabilities

Accessible Polling Places - All polling locations in Massachusetts are required to be accessible. All polling places must provide access on a permanent or temporary basis on Election Day.

Accessible Voting Procedures - A voter can choose someone to assist entering the polling location, checking in, entering the voting booth, preparing the ballot, exiting the booth and checking out.

Accessible Voting Equipment - Both federal law and state requirements mandate that voting systems be equipped for voters with disabilities allowing such voters to have the same opportunity to vote privately and independently. It is required that every precinct must have at least one accessible voting machine available. There is at least one accessible marking unit in every polling place in Massachusetts. The AutoMARK Voter Assist Terminals are marking devices that use audio cue capacity for visually impaired voters. The AutoMark also has a feature that will greatly magnify the ballot or display the ballot high-contrast for voters that have limited visual impairment. The AutoMark can also produce an oral report to the voter as the choices selected prior to the voter printing the ballot. For more information on the AutoMARK Voter Assist Terminal, please visit AutoMARK Video.

For Assistance Contact the Elections Division- The Elections Division of the Secretary of the Commonwealth of Massachusetts is committed to making voting as accessible for all voters. Please let us know how we can improve accessibility by calling us at 800-462-VOTE (8683) (toll free) or 617-727-2828. You may also e-mail us at elections@sec.state.ma.us.

- Source: http://www.sec.state.ma.us/ele/eleaccessible/accessibleidx.htm

Early Voting

Patients who are anticipating hospitalization can get an absentee ballot, or new this year, they can vote early through November 4.

1. Who is eligible to vote early?
If you’ve registered to vote in Massachusetts, you’re automatically eligible to vote early. Registered voters can go to any early voting location in the city or town of their residence, and election officials should have their information.

2. Where can I find my early voting location?
All early voting locations are available on the website of William Galvin, Secretary of the Commonwealth: http://www.sec.state.ma.us/EarlyVotingWeb/EarlyVotingSearch.aspx

If you live in Boston, election officers have also set up their own early voting webpage and sent mailers with polling locations to every home. In Boston, registered voters can cast their ballot anywhere in the city — it does not need to be at their Election Day precinct.

3. What happens to my ballot after I vote early?
According to election officials, ballots are stored and secured until Nov. 8. All ballots, including the ones from voters who made their choice early, will be counted on Election Day.

4. If I vote early, can I change my mind before Election Day?
Nope. Once you’ve cast your ballot, it cannot be changed.
5. Do I still get an “I voted” sticker?
Yes!

-See full The Boston Globe article.

Fuel Assistance (LIHEAP) Season Begins November 1

The Low-Income Home Energy Assistance Program (LIHEAP – commonly  known as Fuel Assistance) provides eligible households with help in paying part of winter heating bills (gas, electric, oil, propane, wood or coal).  Eligibility depends on income, family size and type of living situation. Renters may qualify- even if utilities are included in their rent (learn more). 

Applications are accepted between November 1 and April 30 each winter.

2016 – 2017 LIHEAP Income Limits

Reminder- immigration status requirements were instated last year. Benefits are now limited to “qualified aliens”:

• Legal permanent residents
• Paroled for at least one year
• Refugees
• Granted Asylum
• Granted Withholding of Deportation
• Cuban/Haitian entrants (note: refers to a specific status, not applicable to all who entered from these countries)
• Battered immigrants, parent/child
• Trafficking victims

There is NO five year bar for these qualified statuses. While undocumented immigrants are no longer eligible to receive benefits, mixed households may receive prorated assistance.

To apply:  search for your local agency at:  https://hedfuel.azurewebsites.net/ or call the Massachusetts Heat Line: 1-800-632-8175.

Open Enrollment is November 1 – January 31 for plans that start January 1 or later. Open Enrollment is the time of year when individuals and families may enroll in non-group coverage or switch existing Health Connector coverage for any reason, without needing a qualifying event. (People can apply for and become eligible for MassHealth, the Health Safety Net, or Children’s Medical Security Plan at any time during the year.) Those already enrolled should received notices. While if they are happy with their plan they do not need to take action, the Health Connector strongly encourages all members to comparison shop in order find a 2017 plan that meets their healthcare needs – including cost. There are some significant increases this year.

These charts show varying patient costs and more/less expensive plans.

New this year – no cost-sharing for medication for opioid dependency treatment including –medication-assisted treatment and associated services (counseling, drug screening) and Rescue Opioid Antagonists (e.g., Narcan).

More Information

Health Plan Shopping Guide: https://www.mahealthconnector.org/help-center/resource-download-center

Provider Directory:  https://ma.checkbookhealth.org/ma/index.cfm Note: Even if you use the tool, it's always a good idea to confirm with the plan directly. Also, certain providers such as behavioral health providers, nurse practitioners, physician assistants, and Community Health Centers are not currently listed in the directory, but are expected to be added in time for Open Enrollment.

Source and for more information: Mass Health Care Learning Series, All Assister Conference Call, October 18, 2016.

See related story.

After a long legislative battle and plenty of lobbying, there's some good news to report for Massachusetts older adults and their caregivers. Early this month, Governor Charlie Baker signed into law a spending bill that included $3.78 million for elder home care services. Those funds should end the wait list for home care services that had been implemented on September 1 (see previous coverage - State To Institute Elder Home Care Waiting List, MGH Community News, August, 2016).

The elder care funds were part of a much larger $187.5 million spending bill, the bulk of which will help fund the MassHealth program, which received $164 million. But the $3.78 million slated to go to home care services will make a direct and vital impact on the quality of life for Massachusetts seniors.

Al Norman, the Executive Director of Mass Home Care, who led the lobbying fight to restore the funding to the home care services line item, detailed the impact of the move. "I am very pleased to report that the Governor has signed the supplemental budget bill that includes section 28, which adds $3.78 million to the elder home care services line item, using federal Community First Trust Fund money," said Norman in a press release.

The Governor has rescued these seniors from the No Care Zone, and we thank him and his staff for understanding why a little home care means so much to these families....Even with this funding, the home care programs are just about level to our appropriation level in FY 16 -- so there are still some challenges ahead this fiscal year.”

-See the full Caregiving Chronicles story.

This month the U.S. Department of Housing and Urban Development (HUD) released long-awaited finalized guidance to protect the housing of survivors of domestic and dating violence, sexual assault, and stalking. Read HUD’s final rule.

In an address to the National Coalition Against Domestic Violence in Chandler, Arizona, HUD Secretary Julián Castro emphasized the importance of the rule in building a broad set of housing protections into all of HUD’s key programs. “Nobody should have to choose between an unsafe home and no home at all,” said Secretary Castro. “Today we take a necessary step toward ensuring domestic violence survivors are protected from being twice victimized when it comes to finding and keeping a home they can feel safe in.”
HUD’s rule includes:

• Continuation of the core protections – The rule codifies the core protection across HUD’s covered programs ensuring survivors are not denied assistance as an applicant, or evicted or have assistance terminated due to having been a victim of domestic violence, dating violence, sexual assault, and stalking, or for being affiliated with a victim. 

• Emergency transfers – One of the key elements of the housing protections under the Violence Against Women Reauthorization Act of 2013 (VAWA) are emergency transfers which allows for survivors to move to another safe and available unit if they fear for their life and safety. VAWA required HUD to adopt a model emergency transfer plan for housing providers and to explain how housing providers must address their tenants’ requests for emergency transfers. HUD’s model emergency transfer plan:
• allows a survivor to self-certify their need for an emergency transfer, ensuring documentation is not a barrier to protecting their immediate safety;
• allows the survivor to determine what is a safe unit for purposes of the transfer, ensuring that the survivor has control over their own safety planning;
• requires housing providers to allow for a resident to move immediately if there is another safe and available unit that does not require the survivor to undergo an application process as a new tenant, ensuring quicker access to safe housing;
• requires housing providers to explain the efforts they will take when there is not a safe and available unit available for an emergency transfer and encourages housing provides to partner with victim services and advocates and other housing providers to assist a survivor; and,
• requires housing providers to document requests for emergency transfers, including the outcome of the request, and to report annually to HUD. 
• Protections against the adverse effects of abuse – Domestic violence can often have negative economic and criminal consequences on a survivor. The perpetrator may take out credit cards in a survivor’s name, ruining their credit history, or causing damage to survivor’s property causing eviction and poor rental history. The perpetrator may force a survivor to participate in criminal activity or a survivor may be arrested as part of policies that require arresting of both parties in a domestic disturbance. The final rule ensures that covered housing providers do not deny tenancy or occupancy rights based solely on these adverse factors that are a direct result of being a survivor. 
• Low-barrier certification process – The final rule makes it clear that under most circumstances, a survivor need only to self-certify in order to exercise their rights under VAWA, ensuring third party documentation does not cause a barrier in a survivor expressing their rights and receiving the protections needed to keep themselves safe.

Background

On March 7, 2013, President Obama signed The Violence Against Women Reauthorization Act of 2013 (VAWA 2013) into law. The law significantly expanded the housing protections to survivors of domestic violence, dating violence, sexual assault, and stalking, across HUD’s core housing and homelessness programs. HUD quickly modified its administrative practices to incorporate the core protections, but the more expansive protections required a change in regulation. The final rule recently announced and described above satisfies this requirement. 

Last month, HUD also issued new guidance to assist local governments in the development and implementation of nuisance and crime-free ordinances to make certain they don’t violate victims’ rights under the Fair Housing Act. These nuisance and crime-free ordinances can result in housing discrimination by requiring or encouraging evictions for use of emergency services, including 911 calls. Too often, these ordinances cause survivors of domestic violence to have to choose between keeping their home or protecting their own life. 

- See the original HUD press release.

Additional Information.

After advocacy form disability rights activists, PCAs and the union representing MassHealth has released an update of this PCA OT policy. Basically, MassHealth will pay for current PCA OT through the end of the year, but they are still requiring requests for OT approval to have been submitted by earlier this month (Oct 22). MassHealth will send letters to all members who submit a PCA Overtime Request form confirming approval through at least December 31, 2016. The letter will provide a specific expiration date. MassHealth will be taking the next few months to help consumers recruit additional PCAs and review its continuity of care policy for approving OT. The final process will also define additional situations in which MassHealth will grant a long-term approval. Long-term Continuity of Care approvals will be for the same length of time as the consumer’s prior authorization period. In mid-November 2016, MassHealth will provide updates to the Continuity of Care process and post a simplified PCA Overtime Request

Beginning January 2017, MassHealth will fully implement the PCA overtime management rules with updated Continuity of Care processes and additional consumer support for finding PCAs in place. PCA consumers who have not adjusted PCA schedules to eliminate overtime, must submit a new PCA Overtime Request Form before expiration of their approval.

More info is on the MassHealth website here: http://www.mass.gov/eohhs/consumer/insurance/masshealth-member-info/pca/

-From Health Announcement listserv, Vicky Pulos, Mass Law Reform Institute, October 05, 2016.

The Centers for Medicare & Medicaid Services has just released a comprehensive revision of federal nursing facility regulations. The regulations and explanatory material (over 700 pages total) are available here. The positives for nursing facility residents include expanded training requirements, a new provision that an initial care plan be developed and implemented within 48 hours and limiting facilities’ ability to “dump” resident at hospital. the negatives include a failure to improve nurse staffing standards, and weakening the regulations limiting antipsychotic drug use.

Some important provisions are highlighted below. Additional analysis of the regulations will be developed in coming weeks by Consumer Voice, the Center for Medicare Advocacy, and Justice in Aging.

Quality of Care

Staffing: Although inadequate staffing is the greatest problem in nursing facilities today, the new regulations do not include a minimum staffing standard or a requirement for a 24-hour Registered Nurse. Instead, the new regulations continue the current policy: requiring “sufficient” staffing levels, and registered nurse presence for eight hours daily. Staff must have “appropriate competencies and skills sets,” and staffing levels must take into consideration the number, acuity and diagnoses of the resident population, based on a newly-mandated facility assessment.  

Person-Centered Care: The previous regulations required that care be individualized, and based on a care plan, but the new regulations add emphasis. The new regulations define person-centered care and require that facilities learn more about who the resident is as a person, provide greater support for resident preferences, and give residents increased control and choice.  

Care Planning: Under the new regulations, facilities must develop and implement a baseline care plan for a new resident within 48 hours of admission. The care planning process itself calls for greater resident involvement and participation. In addition, the certified nursing assistant responsible for the resident, and a member of the food and nutrition services staff must participate in the care planning process.  

Abuse, Neglect and Exploitation:  Provisions related to abuse, neglect and exploitation are now included in a separate section, which brings more attention and focus to these issues. New protections include prohibiting licensed individuals with a disciplinary action from being hired, and requiring that suspicion of a crime be reported to law enforcement and the state survey and certification agency.

Antipsychotic Drugs:  Many residents with dementia are inappropriately given harmful antipsychotic drugs, despite strong current federal rules. The new regulations water down existing protections by folding antipsychotic drugs into a broader category of psychotropic drugs, and moving them from quality of care regulations to pharmacy services.  

Training: Training requirements have been expanded to apply to all staff, contractual employees, and volunteers. Mandatory topics include communication, residents’ rights, and abuse, neglect and exploitation. Certified nursing assistants will be required to receive training on dementia management and resident abuse prevention.

Resident Rights

Prohibiting Pre-Dispute Arbitration: Currently, many nursing facility admission agreements include provisions obligating the resident to have disputes adjudicated through private arbitration. Such “pre-dispute” arbitration agreements now will be prohibited. Arbitration agreements will be allowed only when the events at issue occurred before the arbitration agreement was signed.  (See accompanying story)

Improvements to Involuntary Transfer-Discharge Procedures: The new regulations specify that transfer-discharge for non-payment is inappropriate when the resident has submitted necessary paperwork to a third-party payor (such as Medicaid), and that payor is now evaluating the claim for payment. Also, facilities now will be obligated to send a copy of each transfer-discharge notice to the state’s long-term care ombudsman program, which is available to advise the resident.

Limiting Facility’s Ability to “Dump” Resident at Hospital: In an effort to evade transfer-discharge requirements, some facilities “dump” residents by refusing to readmit them from hospitalizations. To address the problem, the new regulations explicitly require a facility to follow the transfer-discharge procedures when the facility claims that a hospitalized resident cannot return to the facility.

Modifying Residents’ Rights to Have Visitors: The new regulations continue current law providing each resident with a right to receive visitors at any time. In an unwelcome change, however, if a visitor is not a family member, the right to receive a visit now is “subject to reasonable clinical and safety restrictions,” as set forth in facility policy.    

Grievances: Far too often, complaints from residents and families have been dismissed or not taken seriously. The regulations will now call for facilities to have a grievance policy and a grievance official to oversee the grievance process. Complainants will receive a written grievance decision that includes the steps taken to investigate, a summary of the finding or conclusions, a statement as to whether the grievance was confirmed or not confirmed, and the action taken or to be taken by the facility.
 
This alert has been jointly developed by Consumer Voice, the Center for Medicare Advocacy, and Justice in Aging. 

-From Justice in Aging, September 29, 2016

Frail nursing home residents and their stressed family members are routinely asked to sign a stack of densely-printed documents at the time of admission, without adequate time to review them or consult with counsel. They often do not realize that the agreements include binding arbitration provisions. Although this might sound benign, arbitration requires a waiver of the fundamental constitutional right to a jury trial, even if the resident later suffers serious injury, medical malpractice, or wrongful death. Under a new federal rule (whose additional important provisions are outlined in an accompanying story), facilities that receive federal funding from Medicare or Medicaid (i.e., virtually all of the nation’s nursing homes) will be prohibited from requiring such waivers, either as a condition of admission to or the right to remain in the facility. The rule, announced by the federal Center for Medicare and Medicaid services, takes effect on November 28, 2016 provides that facilities are prohibited from entering into any agreement for binding arbitration until after a dispute has arisen. If the facility does ask residents to enter into an arbitration proceeding once a dispute has come up, the facility must ensure that the agreement is explained to residents or their legal representatives in a “form and manner” that they understand. 

Because arbitrations are confidential and there is no record of the outcomes, the arbitration requirement has kept issues of abuse and neglect out of the public eye.

Although the new rule is likely to be challenged in court by the nursing home industry, advocates for nursing home residents welcome this new development.

-See the full Margolis & Bloom blog post.

In 2014 and 2015 Department of Transitional Assistance (DTA)​ sent hundreds of thousands of notices to SNAP households based on a match with Department of Revenue ​(DOR) ​wage data and "​new hire"​ data – and then it closed thousands of cases. Advocates from MLRI, Metro West Legal Services and private counsel filed a lawsuit challenging DTA’s wage match procedures. In March 2015 DTA stopped using the wage match information to decide current eligibility – for now.

The lawsuit is now settled. DTA is now​ sending a Settlement Notice to about 28,000 SNAP or cash ​households whose cases closed during this time period​.

See The DTA notice (in English and Spanish).

Households who get the Settlement Notice are not required to do anything. They can contact MLRI for more information. wagematch-info@masslegalhelp.org

What will happen after the Settlement Notices go out? 

• ​​About 17,000 households will get additional SNAP benefits deposited directly to their EBT accounts (they should check their EBT card or call the IVR line for an update).
• Another 7,000 households can re-apply for TAFDC and if approved will get additional SNAP. 
• Households covered by the notice have a right to object to the Settlement. 
• DTA will not re-start use of wage matches for current eligibility unless it has tested the results for accuracy and relevancy and reported to us on the test results. 

Here are the groups:

Group 1 – Automatically get 3 months of back SNAP benefits
You are in Group 1 if DTA closed your household’s SNAP case and did not reopen it by December 17, 2015, and –

• The wage match was for a child under 18, or
• The difference between DOR’s wage information and DTA’s wage information was less than $300.

Group 2 – May get 2 months of back SNAP benefits IF YOU REAPPLY for SNAP benefits and GET APPROVED
You are in Group 2 if DTA closed your household’s SNAP case and did not reopen it by December 17, 2015 and you are not in Group 1.

Group 3 – Automatically get 2 months of back SNAP benefits
You are in Group 3 if you are getting SNAP benefits now and DTA closed your household’s SNAP case but:
DTA did not reopen your SNAP case or pay you back any SNAP benefits you missed while your case was closed, and

• Your case was closed for less than 4 months, or
• DTA had not processed a document in the case when DTA closed the case.

Many legal services and community advocates, the new DTA Administration​ and the USDA Food and Nutrition Service contributed to this terrific result! 

For more information – and any ongoing wage match issues – contact Vicky Negus at MLRI, 617-357-0700 x 315  or go to: wagematch-info@masslegalhelp.org 

Mass Law Reform Institute (MLRI) recently issued some updated information on positive policies DTA has issued around verifications, but also flagged some ongoing problems with the DTA Assistance Line. ​

SNAP (and cash) ​Verification issues

One of the biggest challenges facing our clients is getting DTA verifications (and then getting DTA workers to process them). DTA has been reminding workers about verification requirements via training and issuing short policy "blurbs" that are emailed daily to the field. Asking for unnecessary verifications hurts our clients and makes more work for DTA!  Here's a link to the DTA Blurbs on verifications:  www.masslegalservices.org/content/dta-policy-blurbs-verifications  

The Verification "Blurbs" remind DTA staff that:

• permanent verifications do not need to be verified more than once. 
• certain information should be confirmed via data bases (such as Social Security, SSI, DOR Child Support and Unemployment). Clients do NOT need to produce any statements from SSA! 
• DTA has an obligation under the SNAP rules to assist clients in getting verifications (sometimes called "collateral contact.") 
• One document may serve as proof of several different eligibility factors (for example, pay checks with current address can prove earnings, residency and identity).

​Please be on the look out for excessive or erroneous requests for verifications and let us know what you are seeing. For more information about verification requirements, see Question 11 in the 2016 SNAP Advocacy Guide.

Ongoing DTA Assistance Line Challenges

We know that it has been incredibly hard recently to get through the Assistance Line (877-382-2363). DTA is also aware of this, ​but please continue reporting issues to MLRI and to DTA.

The ​October 2016 ​DTA Scorecard includes data on phone call volume and the number of calls that are blocked (are given a high call volume message and disconnected). In September, on average each day 41% of calls trying to reach a worker were blocked due to high call volume, and the average wait time for callers that were not blocked was 38 minutes. The DTA phone lines are generally worse during the first two weeks or so of the month due to recertification and interim report deadlines which typically come due between the 1st and 15th of each month.  

Strategies to help your clients when you cannot get through the Assistance Line:

• contact the DTA Ombudsman office ​at 617-348-5354​
• contact a local DTA office manager or assistance manager. 
• if neither of those options work, ​you and your clients always have the option to ​contact your local ​State Representative​ or State Senator​ to seek their help.  

For more advocacy tips visit MLRI’s SNAP tri​a​ge page. For Ombudsman and local office contact information see: www.masslegalservices.org/content/dta-local-office-contact-information 

- From Food/SNAP Coalition listserv, Pat Baker, MLRI, October 19, 2016.

Foreclosed Homeowners have 20 years to contest their loss if they enforce that right by end of this year, 2016. 74,000 Massachusetts foreclosed homeowners must take action in 2016 to protect their rights to overturn an illegal foreclosure. The Massachusetts Alliance Against Predatory Lending (MAAPL) has shown that an estimated  95% of the state’s foreclosures contain illegalities. Homeowners of color, women and others were targeted by bank practices & mortgage companies.  Most subprime mortgages were foreclosed in 2005-2009.

Why now?

Foreclosed homeowners have 20 years to reverse an illegal foreclosure and/or get full restitution, BUT a new state law, Chapter 141 of the Acts of 2015, also called An Act to Clear Title to Foreclosed Properties, says foreclosed homeowners must file specific documents at the Registry of Deeds to protect that 20 year window. If a person was foreclosed before 2016: they must file by December 31, 2016. If you were foreclosed recently, or will be foreclosed in the near future, you have three years to similarly file from the date that the foreclosing party records the supposed foreclosure deed.

If you don’t protect yourself during whichever time period applies to you, the foreclosing bank will claim that when a third party (i.e., not the bank, not Fannie Mae nor Freddie Mac) buys the property, the third party has the title to the property. The bank will also then claim that you can never get the property back.

According to their website, MAAPL plans to file lawsuits to ensure that Chapter 141 of the Laws of 2015 is declared invalid, but in the meantime or in case it is not overturned homeowners are advised to protect their rights.

MAAPL is organizing information sessions, complete with individual time to review the most basic illegalities common in foreclosures. You will leave the session knowing what was illegal in your foreclosure. We will arrange dates for large groups to go the same day to Court if you had/have a court case. We will arrange dates for large groups to go to your local Registry of Deeds, so everyone will have support and help to complete their filing to protect their rights.

More Information: MAAPLinfo@yahoo.com or 508-630-1686

The Statewide Young Adult Council (SYAC), a subcommittee of the DMH Youth Development Committee (YDC), is a peer meeting welcoming youth and young adults in recovery. The Council shares resources, works on events, and advises the state on young adult programs. It meets on the third Tuesday of every month in Westborough at the Tatnuck Booksellers (18 Lyman Street).

The next meeting is scheduled for November 15. That meeting will include an open discussion about ways in which schools, non-profits and businesses can improve the services they provide to LGBTQ youth, LGBTQ appropriate terminology, issues in the community and resources available and how to support LGBTQ peers.

Download the flyer

Contact: Joel Danforth, MSW, Success For Transition Age Youth (STAY) Project Coordinator, Massachusetts Department of Mental Health, Child & Adolescent Services, 617-626-8174 or joel.danforth@state.ma.us.

The majority of adult children with significant intellectual disabilities live with their parents or other family members through the child’s 40s, and often 50s. Only about a third of all intellectually disabled citizens in Massachusetts who are served by the Department of Developmental Services (DDS) receive housing provided by the state. These people - tending to be the older or more serious cases - are considered Priority One for housing by DDS. All other DDS clients are either Priority Two or No Priority. (See a description of state-supported housing.)

Adult children served by DDS who cannot live independently without support, but who are not categorized as Priority One, may still have options. Depending upon eligibility, financial assistance to help the child live on his or her own may be provided through a combination of MassHealth’s Adult Foster Care or Personal Care Assistant programs, SSI, SSDI, Section 8, and/or food stamps.

The biggest variable is in the caregiving. If the child can live somewhat independently, work at least part-time for money, and qualify for one or more of the government assistance programs mentioned above, he or she may be able to live successfully outside the family home without financial help from the parents. If the child needs a lot of assistance and is unable to work for money, then the parents probably will have to help pay for the child to live outside the family home, even with government assistance. The “private-pay” amount that parents have to pay can vary from a few thousand dollars a year to $75,000 a year or more, depending primarily on staffing needs. 

When getting started down this road, parents should first consider what housing and staffing model would work best for their child. The basic models for housing outside the family home can be divided into four categories: group homes, shared living, supervised independent living, and community living. Note that DDS will not pay for any of these models if the child is not considered Priority One for housing, in which case the parents will have to work out the finances themselves.

To be eligible for MassHealth long-term care coverage, you must become "impoverished" under the program's guidelines. Without proper planning, nursing home residents can lose the bulk of their savings. Another prevalent concern is retaining the home. Elderlaw firm Margolis & Bloom has posted a blog-post that offers a detailed primer on these issues. View the post: http://www.margolis.com/our-blog/masshealth-planning-and-real-estate

Investigators found "evidence of rodent and insect activity in the rooms of the veterans and in food preparation areas" at a state-run veteran's home in Chelsea, according to State Auditor Suzanne Bump.

An audit released this month found that Soldiers' Home Chelsea "was not providing residents with safe and sanitary living conditions," and said there was evidence of "scattered trash and debris, overloaded electrical outlets, loose and cracked plaster, and evidence of pest and human waste," as well as leaking sewer and water lines, mostly in the 305-bed domiciliary unit.

Bump said the Soldiers' Home has already corrected many of the problems identified in the report. However the Auditor remains concerned about chronic problems with understaffing, procedures and the deteriorating buildings.

“As acknowledged in the 2013-2015 audit, the Chelsea Soldiers’ Home took immediate steps to address and remedy the concerns raised, and is committed to meeting the current and anticipated needs of our aging veterans while fulfilling its mission to provide, with honor and dignity, the highest quality services to Massachusetts veterans," state Veterans' Services spokesman Joe Truschelli wrote in a statement.

Baker's Veteran's Services staff went on to write that Baker's administration have made investments and repairs to the Chelsea facility and is in the process of developing long-term plans for a redevelopment of the campus. A $148,000 feasibility study will look at possible futures for the site.

-See the full WGBH story.

The only designated department of its kind in the country, Boston’s new Office of Housing Stability is carving out its role as a force for fighting displacement under new Deputy Director Lydia Edwards.

Edwards, an East Boston resident with a background in advocacy law, has headed the small office for over a month. They are still staffing up, Edwards said in an interview with the Reporter, and working to define the office’s mission.

“We really have felt that we’re the anti-displacement office,” Edwards said, “ and we didn’t want people to confuse that with being anti-gentrification, or anti-development, or anti-landlord or anything else.” The distinction is relevant because of the myriad ways displacement can occur, whether due to fire or other natural disaster, building condemnation, and evictions, along with the impacts of gentrification.

For an office of a half-dozen people, the flow of cases ranges from 200 to 300 on a monthly basis.

Three staffers are designated housing coordinators, two deal with policy concerns or handle eviction proceedings, and Edwards hopes to bring in an intern to be a presence in following up with cases and monitoring cases that go to housing court.

Mayor Martin Walsh proposed the Office of Housing Stability (OHS) in his 2016 State of the City address, tasking it with “develop[ing] resources for tenants, incentives for landlords who do the right thing, and partnerships with developers to keep more of our housing stock affordable.” About $1.6 million is budgeted for the office.

Edwards said a handful of initiatives are already being eyed to streamline the work that had until recently been scattered across a number of city departments. Metrolist, a database of all affordable housing units in the city, is now managed by OHS.

The office is evaluating existing protocols for displacement across various circumstances. For people who have been displaced due to a fire, Edwards said, “There’s a real clear set of resources, a natural rhythm, and the question is: is it as efficient as possible?” A department-specific app is planned to make sure tenants can easily determine their rights if displaced. In cases of fire, tenants are often unaware that they have access to a landlord’s insurance policy, a $750 payment, a refund of the last month’s rent or security deposit, or other entitlements. “So that’s thousands of dollars already on the table that most people walk away from having no idea that they have those rights,” Edwards said.

Edwards comes to the role from Greater Boston Legal Services, where she observed a “rights knowledge gap” for those who receive an eviction notice.

“What I’ve learned is about 80 percent of evictions never go to court,” Edwards said. “They’re still leaving, because they get a piece of paper, and without any question… people take that as “I’ve gotta go,” and they’re gone before they even think to negotiate. They’re gone before they even know about their rights.” By making sure OHS gets all Notices to Quit, they can get involved early enough to ensure that residents are not being forced out of their homes ignorant of their right to stay put until ordered by a court.

Edwards said night clinics are in the pipeline for tenants working normal 9-to-5 jobs who could only get assistance after hours. The office is also working on mapping out displacement clouds in the city to help them identify areas on the verge of potential upheaval.

Contact and for More Information: Boston Office of Housing Stability  call 617-635-4200, Monday through Friday from 8 a.m. - 5 p.m or email rentalhousing@boston.gov.

-See the full Dorchester Reporter article

Founded in 1984, and located in the Sebago Lake region in Southern Maine, Camp Sunshine provides retreats combining respite, recreation and support, while enabling hope and promoting joy, for children with life-threatening illnesses and their families. Camp Sunshine says they are the only program in the nation offered year-round and serving the entire family. The program is free of charge to families and includes on-site medical and psychosocial support.

Remaining dates in 2016 include a Brain Tumor session December 2 – 4.

Bereavement sessions are also offered for families who have experienced the death of a child from a supported illness.

For more information: https://www.campsunshine.org/

Ten years ago, Metropolitan Boston Housing Partnership (MBHP) started the hoarding and sanitation initiative as a small pilot program designed to prevent Section 8 participants from losing their homes due to hoarding behaviors. Since that time, our program has expanded to become one of the most successful hoarding intervention programs in the country, helping people with any type of housing.

MBHP has expanded our program once again, establishing the Center for Hoarding Intervention, which will serve as the umbrella over three aspects of MBHP’s hoarding work: training; policy, which includes coordinating with replication sites across the country; and direct service.

Our direct service work will continue in our region with a focus on Boston and Cambridge thanks to a recent grant from Tufts Health Plan Foundation.

Hoarding Training Institute

MBHP is pleased to partner with MassHousing and other stakeholders to establish the Hoarding Training Institute, a component of the Center for Hoarding Intervention that will provide training to housing and service providers, first responders, and other professionals in Massachusetts and around the U.S. and Canada in recognizing hoarding and intervening early to avoid crises.

Effective Hoarding Intervention: A manual for non-clinical professionals

MBHP has developed a training manual, Effective Hoarding Intervention. This manual breaks the process down stop-by-step so that it can be utilized by non-clinical professionals to help address hoarding behavior and improve the sanitation of the person’s home. Manuals are available for $20.00 each. Order the manual

Report: Rethinking Hoarding Intervention

Over the past three years, MBHP’s hoarding intervention program has helped more than 150 people avoid eviction and housing loss due to hoarding issues. Learn more in our recent report.

- Source and for more information: http://mbhp.org/?post_type=content&p=106&a=17611&cl=c1d1e6

Believe it or not Thanksgiving is just around the corner. The time for families to register for Thanksgiving food baskets is now. Most programs accept requests through early November. Here is a sampling.

ABCD

Many locations throughout ABCD’s network of neighborhood sites offer holiday meal assistance in the form of food baskets, turkeys, and food supplies that low-income families need to cook and serve holiday meals in their homes.

Holiday Meal services are usually available during the Thanksgiving season and in December. Contact the sites listed below for specific information on availability and application.

• Allston Brighton NOC
• Citywide Boston Hispanic Center
• Dorchester NSC
• East Boston APAC
• Roxbury/N. Dorchester NOC (formerly Elm Hill)
• Jamaica Plain APAC
• North End/West End NSC
• Parker Hill/Fenway NSC
• SNAP/South End NSC
• South Boston APAC
• ABCD South Side

-From http://bostonabcd.org/holiday-meals.aspx

Salvation Army

Every November, The Salvation Army provides Thanksgiving food baskets to individuals and families in need, which include traditional items: a turkey, stuffing, gravy and a roasting pan.

BOSTON Thanksgiving Distribution - Boston Only. (Find another location.).

Pre-Registration: Began October 24 - while supplies last!

Distribution:  Saturday, Nov. 19, 2016

You will need to bring in the following information:

• Picture ID for all the adults living in the household
• Current utility bill (home phone, gas, electric, cable and water) – verifies where you live

Quantities are limited and registration is on a first come, first served basis.

PLEASE NOTE:  REGISTRATION and pickup location is based upon your zip code.
Qualifying families are also invited to pre-register for Christmas Assistance:

-From http://massachusetts.salvationarmy.org/MA/Thanksgiving

Local Food Pantries

Many food pantries also offer Thanksgiving turkeys or food baskets for needy families. Families should apply as soon as possible. Contact Project Bread’s FoodSource Hotline to find a local food pantry. FoodSource Hotline: 800-645-8333, TTY 1-800-377-1292, Monday through Friday 8 am - 7 pm, and Saturday 10 am - 2 pm.

Many of you will be familiar with one of St. Anthony Shrine’s programs- The Lazarus Ministry that provides funeral services and burials for the homeless, the poor, and those who die alone and abandoned. See our Funeral and Burial Resources  packet for more information (p. 9). A recent Boston Herald series highlighted the work two of their other programs:  a women’s health clinic and the Emmaus Ministry for Grieving Parents.

Few clinics in Boston cater to homeless women, much less have a staff member willing to go out searching for them. From 8:30 a.m. to 12:30 p.m. each Thursday, women who are either homeless or at risk of becoming homeless can come without an appointment to St. Anthony Shrine, where, cordoned off by curtains on the first floor, there is an exam room; an office where an AmeriCorps volunteer helps patients apply for insurance, Social Security, food stamps and housing; and a waiting room that’s quiet and welcoming, with sky-blue walls, color-coordinated floral paintings, comfortable chairs and a basket of children’s books such as “My Treasury of Princess Stories” and “The Tunnel of Lost Toys.”

The Boston Health Care for the Homeless Program opened the clinic in March. About half of the women they see struggle with past trauma, including physical, sexual or emotional abuse, and addiction to alcohol or heroin. Some of those patients have transitioned to methadone or Suboxone to reduce cravings for the drug. But others choose to live on the street rather than shelters, chaotic places where their few belongings might be stolen. Some resort to sex work to feed their addiction.

“Setting foot in here at all is a huge first step that they deserve credit for,” Caputo said. “A lot of them are understandably hesitant. They don’t know if they’re going to be judged, because some people view addiction as a moral failure. It’s actually a chronic disease that should be treated as one.”
The clinic offers urgent, primary and preventive care, as well as clothing, snacks and toiletries. The staff schedules tests such as mammograms and colonoscopies at local hospitals.

-See the full Boston Herald article.

Emmaus Ministry for Grieving Parents

One of more than two dozen outreach programs at St. Anthony Shrine in Boston, the Emmaus Ministry offers parent-to-parent companioning, retreats, and monthly Scripture readings and coffee socials for parents whose children of any age have died by any cause.

Although the ministry focuses on the spiritual needs of grieving parents, for Barbara and Rocco Favuzzis it also has had many of the benefits of a support group. They’ve developed friendships with other parents, swapped recipes and checked in with one another regularly, especially on their children’s birthdays.

On their first retreat, the Favuzzis were asked to write a letter to the child they had lost.

Rocco Favuzzi remembers initially finding that first retreat daunting. “I probably wouldn’t have gone if it weren’t for my wife,” he said. “When your child dies, you really don’t know what to do or where to turn. You build up a lot of hurt and guilt. But the (retreat’s) a place where you can release some of it without being put under any pressure to talk. You hear other people tell their stories, and you realize there are people there who’ve had similar experiences. Knowing that helps in its own way. It helps you not get over your loss, but get through it.”

-See the full Boston Herald article.

As many of you have already heard, NHP ConnectorCare patients will be facing a significant premium increase in 2017, due to an increased NHP base premium and a reduction of state subsidies  Beginning in January, these patients with incomes from 0%-300% of the Federal Poverty Level will need to pay between $89 and $165 more per month to stay in their NHP ConnectorCare plan.  The only region not impacted by this premium increase is the Islands (Martha’s Vineyard and Nantucket).  (See The Boston Globe coverage for more background).

Of the five ConnectorCare plans offered in each region, most Partners sites only participate with NHP. 

• NSMC/NSPG also participates with BMC, one of the two lowest cost plans in most regions
• Spaulding Rehab hospitals and SNFs also participate with CeltiCare, but CeltiCare remains one of the higher cost plans in each region

So with the exception of North Shore and the Islands, our ConnectorCare patients will be faced with two options for 2017: (1) pay significantly more to stay with their Partners provider or (2) switch providers.

Please note: This premium increase does not apply to patients on NHP through MassHealth or their employer group.   NHP commercial members who purchased insurance on the Health Connector will, however, have a premium increase. 
How many patients does this affect? 

We currently have 7,300 NHP ConnectorCare Primary Care patients. 

• 1,240 of these patients are from the Islands, so they will not have a premium increase.
• 1,375 of these patients see NSMC/NSPG provider, so will have another ConnectorCare plan option with BMC.

This leaves roughly 4,700 patient who will need to pay the increased premium to stay with their Partners provider. 
There are also patients who may have primary care providers elsewhere but who come to us for specialty care and will lose access to us as well if they cannot afford the higher premium.  We do not have data on the number of specialty patients this affects.

When can a patient switch plans?
ConnectorCare patients can switch plans during Open Enrollment, November 1, 2016 – January 31, 2017.  After the Open Enrollment Period ends on January 31, ConnectorCare patients will not be able to switch plans until October 1, 2017 for a January 1, 2018 effective date (unless they qualify for a Special Enrollment Period). 

What happens if an NHP ConnectorCare patient does nothing?
If an NHP ConnectorCare patient takes no action, they will be automatically enrolled in NHP with the higher premium for 2017.  If they cannot afford their premiums after Open Enrollment ends and stop paying, they will be terminated from their plan and will be locked-out of health insurance until next Open Enrollment.  These patients do not have access to Health Safety Net (HSN) and cannot purchase private insurance. 
Note: ConnectorCare patients can miss their premium payment for three months before being dropped from their plan.  After they are dropped, however, they will be retroactively disenrolled for two months.  Patients will be self-pay for those two months.  

What is our Communication Plan?
Partners is working closely with both NHP and the Connector on their communication plans.  Both will be sending a patient letter and will have other direct outreach to patients. Partners is undertaking a variety of efforts  to  train hospital staff, physician organizations and patient financial counselors about the changes including notices, presentations, and scripts.

-Adapted from materials from, and thanks to Brooke Alexander, Senior Program Manager for Public Payer Patient Access, Partners Community Health.

A health savings account (HSA) is an account that works with a high deductible health plan (HDHP). Many people have an HSA through their current employer. If you have an HSA you can contribute to it on a tax-free basis and use those funds to pay for qualified health expenses as long as you meet certain IRS requirements.

If you have an HSA and you will soon be eligible for Medicare, it is important to plan ahead and understand how enrolling in Medicare will affect your HSA.

1. You cannot be enrolled in Medicare Part A and/or B and contribute to your HSA. By law, people with any other health insurance, including Medicare, are not allowed to put money into an HSA. However, you may continue to withdraw money from your HSA. If you use the account for qualified medical expenses, including Medicare deductibles, premiums, and copays or coinsurances, it will continue to be tax-free.  
2. To avoid a tax penalty, stop HSA contributions six months before you decide to collect Social Security benefits. If you do not take Medicare when you first qualify, you must take special precautions if and when you do decide to collect Social Security benefits (either while working or when you retire). You should stop all contributions to your HSA up to six months before you collect Social Security. This is because when you apply for Social Security, Medicare Part A will be retroactive for up to six months (as long as you were eligible for Medicare during those six months). If you do not stop contributing to your HSA six months before you apply for Social Security, you may have a tax penalty. The penalty is because you cannot have contributed pre-tax dollars to the HSA while you had Medicare.

If you have an HSA through your current employer and are thinking of delaying Medicare enrollment, you should also consider if your employer plan will pay primary or secondary to Medicare, and therefore whether it is wise to delay Medicare.

Planning ahead can help you avoid penalties and gaps in coverage. You can speak with your employer’s benefits administrator about your situation and options.

-From Dear Marci, Volume 15, Issue 16, Medicare Rights Center, August 08, 2016.

This month, the Medicare Rights Center released a new brief on the complexities of knowing when to enroll in Medicare Part D and the consequences of making mistakes. The brief, Medicare Snapshot: Stories from the Helpline, Part D Enrollment: Penalty Pitfalls, reports on a recurring issue heard on the Medicare Rights national helpline.

Since 2006, people with Medicare have benefited from access to coverage for prescription medications by enrolling in private insurance plans through Medicare Part D. People eligible for Medicare who fail to enroll in Part D face a late enrollment penalty unless they have other creditable coverage, meaning a prescription drug plan that provides equal or greater value than the standard Part D benefit.

Many such penalties can be avoided. Yet, for various reasons, people new to Medicare miss key information they need to make informed decisions about their health care coverage. Oftentimes there is simply inadequate information or insufficient assistance for people with Medicare when it comes to the Part D late enrollment penalty.

To address these Part D enrollment pitfalls, Medicare Snapshot outlines needed improvements to the Medicare enrollment process, including:

• Ensuring that Part D plans are not erroneously assessing penalties for their members;
• Examining the effectiveness of creditable coverage notices; and
• Enhancing beneficiary education and outreach.

For those eligible for Part D, Medicare Snapshot offers important advice, including:

• When you become eligible for Medicare, you should enroll in a Part D plan unless you have other creditable prescription drug coverage. Creditable prescription drug coverage is coverage that is considered to be as good as or better than Part D. Your employer (or other entity providing prescription drug coverage) should inform you whether or not your coverage is creditable. If you do not receive this information, you should ask for it.
• Hold onto any notice of creditable coverage that you may receive. Keep this in a safe place just in case you have to prove your creditable coverage.
• If you have been without creditable drug coverage for more than 63 days while eligible for Medicare, you may face a lifetime Part D late enrollment penalty that must be paid or you will likely lose your coverage.
• Everyone has the right to appeal their penalty.

A recent Medicare Rights Center “Ask Marci” column also addressed this topic and included this additional advice:

• If you drop or lose your creditable prescription drug coverage through no fault of your own, you will have a Special Enrollment Period (SEP) to sign up for Part D for up to 63 days after your coverage ends. If you drop or lose your current or former employer-based prescription drug coverage, regardless of whether it is creditable, you will also have an SEP to sign up for Part D for up to 63 days after coverage ends. In order to avoid a late enrollment penalty, this employer-based coverage must have been creditable.
• There may be consequences if you sign up for Part D in addition to your current drug coverage. You should ask your employer or retirement benefits administrator if you can keep their coverage and have Part D at the same time. You could lose your employer, retiree, or other benefits if you sign up for a Part D plan. It is important to keep this in mind if your plan covers a spouse or dependents because if you lose coverage, they will too, and it is unlikely you will be able to get the coverage back.

More Information on Medicare Interactive

• Part D Late Enrollment Penalty
• Appealing the Part D Late Enrollment Penalty

-See the original Medicare Rights Center blog post.

-Additional material from Dear Marci, Volume 15, Issue 21, Medicare Rights Center, October 17, 2016.

Extra Help is a federal program that helps pay for some to most of the costs of Medicare prescription drug coverage (Part D). You may be eligible for Extra Help if your monthly income is up to $1,505 ($2,022 for couples) in 2016 and your assets are below $13,640 ($27,250 for couples). If you are enrolled in Medicaid, a Medicare Savings Program, or you receive Supplemental Security Income (SSI) you will get Extra Help automatically, and you do not need to apply. You can apply for the Extra Help program through the Social Security Administration or your local Medicaid office.

Learn more about Extra Help on Medicare Interactive.

-From Medicare Watch, Volume 7, Issue 39, The Medicare Rights Center, October 20, 2016

Boston’s $2,072 average rental rate is the third-highest in the U.S., according to the third-quarter apartment sector survey by New York-based real estate research firm Reis, Inc. The Reis report said New York and San Francisco, the two cities with the highest apartment rents in the country, both saw negative rent growth in the third quarter from the second quarter. But Boston saw a 0.9 percent increase

The city outstripped San Jose, California, which posted an average effective rent of $2,053 in the third quarter. New York’s average effective rent declined 0.1 percent in the quarter to $3,441, while San Francisco’s declined 0.8 percent to $2,481.

Boston has seen 4.3 percent growth in effective rent in the past year, the Reis report said, with an apartment vacancy rate of 5 percent.

-See the full  Boston Business Journal article.

Changing the way it does business, Medicare recently unveiled a far-reaching overhaul of how it pays doctors and other clinicians. The goal is to reward quality, penalize poor performance, and avoid paying piecemeal for services. Whether it succeeds or fails, it’s one of the biggest changes in Medicare’s 50-year history.

The complex regulation is nearly 2,400 pages long and will take years to fully implement. It’s meant to carry out bipartisan legislation passed by Congress and signed by President Obama last year.

The concept of paying for quality has broad support, but the details have been a concern for some clinicians, who worry that the new system will force small practices and old-fashioned solo doctors to join big groups. Patients may soon start hearing about the changes from their physicians, but it’s still too early to discern the impacts.

Officials said they considered more than 4,000 formal comments and held meetings around the country attended by more than 100,000 people before issuing the final rule. It eases some timelines the administration initially proposed, and gives doctors more pathways for complying.

The American Medical Association said its first look suggests that the administration ‘‘has been responsive’’ to many concerns that doctors raised.

MACRA, the Medicare Access and CHIP Reauthorization Act, creates two new payment systems, or tracks, for clinicians. It affects more than 600,000 doctors, nurse practitioners, physician assistants, and therapists, a majority of clinicians billing Medicare. Medical practices must decide next year what track they will take.

Starting in 2019, clinicians can earn higher reimbursements if they learn new ways of doing business, joining a leading-edge track that’s called Alternative Payment Models. That involves being willing to accept financial risk and reward for performance, reporting quality measures to the government, and using electronic medical records.

Medicare said some 70,000 to 120,000 clinicians are initially expected to take that more challenging path. Officials are hoping the number will quickly grow.

Most clinical practitioners — an estimated 590,000 to 640,000 — will be in a second track called the Merit-Based Incentive Payment System. It features more modest financial risks and rewards, and accountability for quality, efficiency, use of electronic medical records, and self-improvement.

Finally, about 380,000 clinicians are expected to be exempt from the new systems because they don’t see enough Medicare patients, or their billings do not reach a given threshold.

Advocates say the new system will improve quality and help check costs. But critics say complicated requirements could prove overwhelming. The administration says some doctors will be pleasantly surprised to find out that reporting requirements have been streamlined to make them easier to meet.

-See the full Boston Globe article.

MassHealth has established a program of hospital incentive payments that all managed care organizations (MCOs) are required to implement. In MCO Contract Year 2017 (October 1, 2016, to September 30, 2017) MassHealth-contracted MCOs are required to make these payments to acute hospitals in their MCO networks if those hospitals meet certain performance measures set forth in the MCO contract. Specifically, acute hospitals must report certain information related to access to medical and diagnostic equipment for MassHealth members with disabilities. MCOs will verify and report this information to EOHHS. New performance-based MCO hospital payments will be announced annually.

Measures for MCO Contract Year 2017 (October 1, 2016, to September 30, 2017)

EOHHS continues to look for ways to improve access to care for MassHealth members with disabilities. Improving access to medical and diagnostic equipment is a critical component of these efforts and of MassHealth’s overall quality strategy moving forward. Consistent with these efforts and strategy, MCOs are required to provide these payments to acute hospitals in their networks if those hospitals provide the MCOs with the following information:

• the hospital’s capacity to provide accessible medical and diagnostic equipment to individuals with disabilities;
• a detailed list of the hospital’s accessible medical and diagnostic equipment;
• the hospital’s plan to improve its provision of accessible medical and diagnostic equipment for individuals with disabilities; and
• the name and contact information for the hospital’s single point of contact for those with questions about access for individuals with disabilities (i.e., a Disability Access Key Contact, as described in the MCO Contract).

-See the full MassHealth Acute Inpatient Hospital Bulletin 158,  October 2016.

When a furor erupted over the rapidly rising price of EpiPens this summer, the drugmaker Mylan offered a solution: a coupon for the expensive drug.

People who need the EpiPens to protect themselves from life-threatening allergic reactions could use the coupon to get up to $300 off at the pharmacy counter if their insurance plan has a deductible or a co-payment.
It is a good deal for those people. But these seemingly generous coupons may be making drug costs higher for everyone. New research suggests that co-payment coupons can actually increase total health care spending by encouraging patients to choose more expensive drugs when there are lower-priced substitutes available. Those high costs can then boomerang back to patients in the form of higher insurance premiums.

Mylan is not the only drug company to offer such coupons. They are common in the industry and used for drugs for many diseases, including heart disease, diabetes, skin problems and mental illness.

The negative effects of coupons have long been suspected, but a pair of new papers this month one published in The New England Journal of Medicine and one published by the National Bureau of Economic Research, are the first to precisely measure the effect.

A research team from Harvard, Northwestern and the University of California, Los Angeles, looked at brand-name drugs that also had generic equivalents. When drug companies offered a coupon for the brand-name version, more patients stuck with the more expensive brand-name drug, and the company raised the prices on such drugs faster than it did for drugs for which no coupon was available.

Altogether, the researchers estimate that coupons for 23 such drugs with a generic alternative resulted in an extra $700 million to $2.7 billion in spending on drugs over five years. (Because generic drugs are required to be biologically identical to their brand-name cousins, the more expensive brand-name version doesn’t make patients any healthier.)

“These are wolves in sheep’s clothing,” said Leemore Dafny, a professor at Harvard Business School and a co-author of the research. “These efforts to help consumers bear the cost of their drugs are actually driving higher spending without commensurate health benefits.”

-See the full The New York Times article.

The issue of leaving an inheritance often comes into play when seniors' care costs increase and they begin digging into their savings. In our practice we've seen many seniors who are reluctant to do so both because of their concern about running out of funds themselves and their desire to be able to leave something to their family. This can mean a huge sacrifice for family caregivers, whether spouses or children. While I often urge families to spend money as necessary to avoid "burning out" caregivers, the problem for families is often that they don't know how long a chronic need for care will last. Will it be months or years? A few months of high costs may be affordable, but if the need for care lasts for years, what will the family do if the money runs out?

The decision can be a bit easier if the issue of preserving money for an inheritance is taken off the table. In a column in The New York Times, "The Children will be Fine. Spend their Inheritance. Now." Ron Lieber tells his parents:

I expect nothing from you going forward except love, conversation, holiday meals and grandchild babysitting. Spend your money on your health and comfort and making the kinds of memories with close friends and family members that will last even as other, older ones, fade. Leave a bit aside for me or for charity if it truly makes you happy, requires no sacrifice or makes sense for tax reasons. But otherwise, spend what you have and have faith that the education and life skills you already gave me are more than enough.

Of course, there are other children who are looking forward to the inheritance, perhaps to help finance their own retirement. They may well argue against spending money on care or choose the cheaper of various care options. These issues often play into questions about MassHealth planning and reverse mortgages.

-For more on MassHealth planning and reverse mortgages see the full Margolis & Bloom blog post.

This blog post is the third in a series discussing how vulnerable segments of the US population interact with and experience the health care system. This research is part of the Robert Wood Johnson Foundation’s Right Place, Right Time initiative.

For our Right Place, Right Time research initiative, launched in January 2016, we interviewed vulnerable patients, including low-income patients, the uninsured, family caregivers, and non-English speakers, to learn their most urgent concerns about the health care system and the information they need to make health decisions. We expected to hear that health care information was too confusing and price information was difficult to find—and we have—but the issue lower-income participants were most passionate about surprised us: they reported widespread distrust of the health care system and the feeling that they were seen as “less than” by health care professionals.

For many lower-income participants, trust and respect were their primary concern with the health care system, even more than the quality of the health care they received. Participants felt they were treated with less respect because of their income, insurance status, and race. This is consistent with past research finding that distrust in the health care system is high, and strongly associated with poor health.

In contrast, middle-income study participants did not report many negative experiences with providers, and those with negative interactions did not feel they were being targeted or discriminated against. It was as if lower- and middle-income patients had experienced two different health care systems.

Lower-income participants gave examples of a lack of trust and respect, including providers avoiding eye contact, speaking condescendingly, showing physical disgust when touching patients, brushing off patient concerns and symptoms, and ignoring adverse events that patients reported from prescribed treatments. Most of this criticism was directed at physicians of all types, and less directed at nurses and other provider types, who were perceived as having more in common with patients and as having no financial motivations in providing care. It was clear from participants’ descriptions that these events colored the entire patient experience and were highly influential in determining the care they later sought and received.

Medicaid Beneficiaries Report Poorer Treatment

Many participants felt that Medicaid beneficiaries were often not taken seriously, regardless of the symptoms they presented.

Many participants also felt that their medical concerns were downplayed because of their insurance, and that they received better treatment when they had commercial insurance.

-See the full Health Affairs blog post for more on the health impacts of poor patient-provider relationships and recommendations.