Highlights

• Transgender Rights Law
• SNF Resident's Rights for Community Living Review
• Braemoor Sanctions
• Group Homes Fail to Report Abuse
• Homeless Children's Education Rights
• Boxborough Rental Assistance
• MassHealth Tightening Frail Elder Waiver Eligibility

Sections

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

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

TAFDC Clothing Allowance

As part of the state budget process for fiscal year 2017 that began July 1, the legislature had proposed an increase in the TAFDC September Clothing Allowance from $200 to $250 per eligible child. The Governor vetoed this provision, but the legislature overrode the veto, so this increase will go into effect in September. Watch this space for our yearly reminder with more details next month.

Counting SSI for TAFDC Eligibility

The Governor had also sought to change TAFDC financial eligibility rules to begin counting Supplemental Security Income — or welfare for people with severe disabilities — while determining a family’s eligibility for the TAFDC. The average SSI benefit is $750 per month, while the current average TAFDC benefit is $448 per month, according to Baker’s office. Under current state policy, which has been in effect since 1972, SSI is not counted while determining the household size and none of the benefits are counted toward the cash benefits for the family. Advocates estimated this change would knock 6,900 disabled families off the welfare rolls and cut benefits for another 1,600 and put them at risk for homelessness. The legislature had removed this provision, the Governor vetoed that language, but the legislature subsequently overrode his veto. Going forward SSI will continue not to be counted in TAFDC eligibility calculations.

RAFT Expansion Vetoed- Awaiting Decision on Override

Advocates had pushed legislation, passed by the legislature, to expand the Residential Assistance for Families in Transition (RAFT) homelessness prevention program beyond just families with children under the age of 21 to include households of all sizes and configurations, including elders, unaccompanied youth, and people with disabilities. Governor Baker vetoed the expansion. The legislature has until midnight on July 31 to take up an override. If they do not override the veto RAFT will continue to only be available to families with children.

-See the full Boston Herald article. Additional material from e-mail correspondence and presentation at the Coalition for the Homeless Housing and Benefits meeting by Kelly Turley, Mass Coalition for the Homeless, July 29, 2016

Ending a years-long campaign filled with rhetoric about civil rights and public safety, the Massachusetts Legislature this month voted to extend anti-discrimination protections to transgender people in public places, and Governor Baker subsequently signed it into law.

The law will ensure that transgender people cannot be discriminated against in places of public accommodation, such as restaurants or on public transit. Someone who is transgender would be allowed to use the bathroom or locker room of the gender with which they identify, rather than their biological sex.

The final version of the bill makes the protections effective Oct. 1. The Massachusetts Commission Against Discrimination (MCAD) and Attorney General Maura Healey are instructed to begin writing regulations immediately, with those guidelines due by Sept. 1.

Under the bill, someone must have a sincerely held gender identity in order to take advantage of the protections, and someone cannot assert their gender identity for an improper purpose.
MCAD will develop guidelines to determine what evidence can be used to show the sincerity of someone's gender identify, and under what conditions evidence should be shown. Healey would be tasked with defining what an improper purpose is and under what circumstances a complaint can be made to law enforcement or to a state agency.

-See the full MassLive article.

Recent federal guidance instructs nursing facilities on how to better identify and support residents who want to move to community settings. As the guidance notes, unnecessary nursing facility placement may constitute illegal disability-based discrimination.

The guidance concerns how a facility should administer an assessment document called the Minimum Data Set - MDS for short. Since 2010, the MDS has included Section Q, which is designed to determine a resident’s interest in moving from the facility to a community setting. According to the HHS Office of Civil Rights - the author of the guidance -  many nursing facilities are administering Section Q improperly, which results in residents being deprived of opportunities to move from facilities into community settings.

One MDS question asks if “active discharge planning” is occurring. The Office of Civil Rights reports that too many facilities are answering “yes” based on the file containing a pro forma “discharge plan” that has no practical effect. Under MDS assessment protocols, this “yes” answer results in the resident not being asked whether he or she wishes to speak to someone about the possibility of moving from the facility into the community.

The guidance also identifies problems in how the facilities ask whether the resident wishes to speak to someone about possibly moving into the community. The guidance instructs facilities to emphasize that the resident does not need to know exactly how or whether a move would take place: the resident just needs to have an interest in the possibility of moving.

Finally, the guidance advises that interested residents be referred to the “Local Contact Agency” designated to assist residents in moves into the community. A facility should not short-circuit the process based on its estimation that the resident would not be able to live in the community, or on the opinions of the resident’s family.

- From Civil Rights in Nursing Facilities, Justice in Aging, July 05, 2016.

State regulators have declared that residents at a troubled Brockton nursing home are in “immediate jeopardy” after finding that workers failed to respond appropriately when one resident suffered a heart attack and another desperately needed oxygen.

The state health department on July 1 ordered the nursing home, Braemoor Health Center, to stop accepting new patients, threatened to remove it from government programs that cover most residents’ bills, and recommended fines as high as $10,000 a day until safety is restored.

Federal regulators said in a letter dated July 22nd that while the home has resolved urgent health and safety issues, because other problems remain, sanctions - including fines and a ban on new residents - will stay in place until those issues are addressed.

Braemoor is one of 11 Massachusetts nursing homes owned by Synergy Health Centers of New Jersey, a problem-plagued company that was slapped in April with what regulators characterized as unusually steep federal fines after two deaths at the company’s Wilmington facility, Woodbriar Health Center.

The federal Centers for Medicare & Medicaid Services fined Woodbriar $288,400 for health and safety violations in connection with resident deaths in February and December.

In response to the latest violations, a spokeswoman for Synergy issued a one-sentence statement and declined to comment further.

“We are working with the Department of Public Health to be in compliance,” the statement said.

See related coverage: Nursing home owners profited as complaints rose

-See the full Boston Globe article.

A scathing federal audit released this month faults Massachusetts officials for frequently failing to alert authorities when developmentally disabled residents of the state’s group homes suffer broken bones, burns, and other injuries potentially caused by abuse and neglect.

The audit, by the inspector general of the US Department of Health and Human Services, found that 58 percent of emergency room visits that involved reasonable suspicion of abuse and neglect were not reported to investigators between January 2012 and June 2014.

In one case, a developmentally disabled man had second-degree burns on his shoulder that neither he nor an aide at his group home could explain.In another case, a woman prone to seizures and defiant behavior was brought to the emergency room on two separate occasions with cuts on her head after she was restrained by group home staff. And in a third, an autistic man had a bed sore that was so infected it was possibly gangrenous and in need of extensive surgery and reconstruction.

State officials said they disagreed with many of the findings of the report, which they said were overstated. Nevertheless, they said they had issued several new advisories to group home contractors on how to identify suspected abuse and neglect and are developing additional training for group home workers and state officials.

Private contractors operate about 1,800 group homes in Massachusetts, while the state directly runs about 200, according to the Arc of Massachusetts, an advocacy group for people with developmental disabilities. They serve a total of 10,000 residents with disabilities.

The federal audit found the lack of action by state officials and group home workers placed developmentally disabled adults – some of whom cannot speak, hear, or see, and many of whom have serious physical and intellectual disabilities – at risk of harm. The state’s failure to report the injuries to investigators also violated state and federal rules.

Christine Griffin, executive director of Disability Law Center of Massachusetts, said she hopes the report prompts officials to overhaul how the state handles potential abuse and neglect – including what she called the chronic underfunding and understaffing of the Disabled Persons Protection Commission, which investigates possible cases in group homes.

She said the state should also implement, as others have, a registry of group home workers who have abused or neglected residents, to ensure they can’t be hired again at another group home.

“It’s startling to me that we’re this behind,” Griffin said. “Especially someone who is nonverbal, we just discount what happens to them in some way. If they can’t say, ‘Somebody did this to me and this is who that person is,’ then things that happen to them get ignored by everybody.”

Nancy A. Alterio, executive director of the Disabled Persons Protection Commission, said the agency fields 10,000 reports of potential abuse and neglect a year, has a $3 million budget and five investigators. Each investigator typically has 50 open cases.

-See the full Boston Globe article.

The U.S. Department of Education recently released guidance to states and school districts on the new provisions in the Every Student Succeeds Act (ESSA) for supporting homeless youth. The new provisions address the needs of homeless individuals, and ensure educational rights and protections for homeless children and youth. The guidance released this month will assist state and local partners in understanding and implementing the new law in order to better protect and serve homeless students and help schools in providing these students with much needed stability, safety, and support. The guidance was informed by the input of a diverse group of stakeholders to best address the needs of homeless youth.

In December 2015, ESSA reauthorized the McKinney-Vento Education for Homeless Children and Youths program, which protects and serves homeless students. The amended McKinney-Vento Act provides new protections for homeless youth, and equips local partners with an essential tool for implementing new provisions in ESSA. The new guidance helps states, districts, and local partners understand the new provisions, which take effect October 1, 2016. Among other changes, the amended McKinney-Vento Act includes new requirements focused on:

• Identification of homeless children and youths;
• Making sure that preschool-aged homeless children have access to and receive supportive services;
• Ensuring coordination with other service providers, including public and private child welfare and social service agencies; law enforcement agencies; juvenile and family courts; agencies providing mental health services; domestic violence agencies; child care providers; runaway and homeless youth centers; providers of services and programs funded under the Runaway and Homeless Youth Act; and providers of emergency, transitional, and permanent housing, including public housing agencies, shelter operators, and operators of transitional housing facilities;
• Providing professional development and technical assistance at both the State and local levels;
• Removing enrollment barriers;
• Providing school stability, including the expansion of school of origin to include preschools and receiving schools and the provision of transportation until the end of the school year, even if a student becomes permanently housed;
• Protecting privacy of student records, including information about a homeless child or youth’s living situation;
• Improving the dispute resolution process for decisions relating to the educational placement of homeless children and youths;
• Increasing the emphasis on college and career readiness; and
• Establishing a new authority for local liaisons to verify the eligibility of homeless children, youths, and families for HUD homeless assistance programs.

The new guidance in its entirety can be found here. This guidance is part of a series of guidance documents that will be released on the new provisions in ESSA.

College Financial Aid

The Department of Education also recently announced changes to streamline the way homeless students gain access to financial aid for college. Included in the changes, all students who indicate on the FAFSA that they're homeless will automatically have the option to select that they've already received an unaccompanied homeless youth determination which means they will be considered “independent” for the purposes of financial aid eligibility, and won’t need to provide their parent’s financial information. The Department also released a fact sheet to help homeless students navigate the FAFSA. In response to the growing number of homeless students enrolled in public schools, President Obama’s fiscal year 2017 budget also calls for a 21 percent increase to the Education for Homeless Children and Youths program, which helps reduce and eliminate educational barriers for homeless children.

-See the US Department of Education press release.

The Boxborough Rental Voucher Program (BRVP) will provide rental assistance to income eligible households renting qualifying housing units in the town of Boxborough. The rental assistance available through the program will be provided for a period of one-year, with an amount of approximately $250/month available to each participating household. Rental assistance payments will be made directly to the landlord.

The BRVP is a new Boxborough program that is funded by the Community Preservation Act (CPA). The CPA funding is annually appropriated by Town Meeting, and this first year of the BRVP is a pilot program. If the BRVP is successful, it will likely be continued by next year’s Town Meeting.

Households that pay more than 30% of their income towards rent are eligible for assistance. Participants will be selected by a Preference ranking system. While the BRVP is not limited to Boxborough residents, assistance will be available only for residential rental units within the Town of Boxborough.

Applications for assistance will be accepted from July 1, 2016 through August 16, 2016. Rental assistance will begin as early as September 1, 2016 and will continue for a one-year duration after the start of the assistance. Further assistance will depend upon the applicant’s status and the approval of future funding for the BRVP by the CPC and Town Meeting.

BRVP applications and information packets will be available at Boxborough Town Hall, the Sargent Memorial Library, the Town of Boxborough municipal website, and by contacting the Town of Boxborough Community Services Coordinator. Applicants have the right to request a reasonable accommodation, which may include a change to a policy, procedure, or practice to afford a person with a disability an equal opportunity to participate fully in the housing program or to use and enjoy the housing.

Eligibility

1. The annual household gross income must be less than 60% of the Area Median Income for the household size.



Household Size	1	2	3	4	5	6
Income Must be LESS THAN	$41,250	$47,150	$53,050	$58,900	$63,650	$68,350



2. After assistance is awarded, a household must not pay more than 50% of its income on housing.
3. No household member can own a home or have any other ownership interest in real property.
4. The household must not be receiving assistance from a tenant-based rental assistance program funded and administered by the federal or state government, or any other entity.
5. The household must occupy the rental housing unit assisted through the BRVP as their primary residence.
6. The household must agree to work with the Town of Boxborough Community Services Coordinator to develop a strategy that supports a sustainable long-term housing situation. If a household is accepted for assistance by the BRVP, the monthly stipend will be paid directly to the landlord, and the landlord must agree to accept these payments. The rental agreement with the landlord must be at least a Tenancy-at-Will Lease.

For more information and the application see: Town of Boxborough municipal website

Medicare Interactive, from the Medicare Rights Center, now includes a Medicare eligibility roadmap. Designed to be an easy-to-use decision tool to help Medicare members, their loved ones, and others navigate Medicare. Medicare eligibility is dependent on several factors, including age, work history, and citizenship status.

After learning your Medicare eligibility, you may have additional questions about Medicare costs and coverage or want to know how Medicare coordinates with other forms of health insurance -  see their other Roadmaps on these topics.

Note: Only the Social Security Administration can confirm your Medicare eligibility. If you still have questions or concerns after using our tool, please call SSA’s helpline at 800-772-1213 or visit their website.

See the “Am I Eligible for Medicare” Roadmap on Medicare Interactive.

-From Medicare Watch, Volume 7, Issue 2, The Medicare Rights Center, June 30, 2016.

Medicare covers diabetes supplies in different ways depending on what you need. Original Medicare Part B (medical insurance) covers some diabetes supplies, and Medicare Part D (prescription drug benefit) covers others.

Specifically, Part B covers certain diabetes supplies as durable medical equipment (DME). This means that you must get a prescription from your doctor and use an appropriate provider. For Original Medicare, this can be a supplier that is part of a competitive bidding program or a Medicare-certified supplier, depending on where you live.
Part B covers the following 

• Glucose 
• Blood sugar (glucose) test 
• Lancet devices and Insulin used with an insulin glucose control solution
• Therapeutic shoes or inserts
• Insulin that is used with an insulin pump

You pay 20 percent of the cost of the Medicare-approved amount and Medicare pays 80 percent of the cost. If you have questions about durable medical equipment and diabetes supplies, you can call 1-800-MEDICARE for more information, and to find a supplier in your area.

Alternatively, if you inject your insulin with a needle, then Part D covers the cost of insulin and the supplies necessary to inject the insulin. This includes syringes, needles, alcohol swabs, and gauze. Your stand-alone Part D plan will also cover other medications to treat your diabetes at home, as long as they are on your plan’s list of covered drugs.

Depending on the type of supplies you are using, either Medicare Part B or Part D will cover the cost of the supplies you need. You can speak with your doctor to learn more about your health care needs.

Also see the detailed reference sheet: Diabetes Services and Supplies that Medicare Covers

-From Dear Marci, Volume 15, Issue 15, The Medicare Rights Center,  July 25, 2016.

A significant change is anticipated this fall for married elders seeking eligibility for the MassHealth Home and Community-Based Services (HCBS) waiver in Massachusetts. The Commonwealth is very likely to begin imposing an asset limit of $119,220 for the community spouse of HCBS waivers. There is currently no asset limit for the community spouse of applicants for the HCBS waiver. This will apply to new HCBS applicants and HCBS waiver applicants who started receiving benefits beginning January 1, 2014. 

If you are married and your spouse began receiving HCBS waiver services after January 1, 2014, and you have more than $119,220 in assets, your spouse may no longer receive HCBS waiver services come this fall.

The Executive Office of Health and Human Services is holding a public hearing on this issue on Tuesday, August 9th at 10:00am. Massachusetts NAELA’s public policy committee is actively working to defeat this change.  

Those in this position are advised to consult an elder law advocate such as Patricia C. D’Agostino, from Margolis & Bloom (who authored this post) at (617) 267-9700, ext. 562.

-See the full Margolis & Bloom blog entry.

MassHealth is amending the Personal Care Attendant program regulations to establish limits on the utilization of Personal Care Attendant (PCA) overtime hours.

Beginning September 1, 2016, a consumer of PCA services will be limited to scheduling individual PCA providers to work no more than 40 hours per week unless the consumers have MassHealth approval for overtime. Additionally PCA providers will be limited to working no more than 40 hours per week, whether for one consumer or in total for work performed for multiple consumers. Prior to September 1, 2016, there will be a transition period to enable continuity of care while members obtain additional PCAs or adjust PCA schedules if needed.

Under the revised regulation, consumers may request an overtime approval from MassHealth to schedule an individual PCA to work more than 40 hours per week under the following circumstances: 1) the consumer has prior authorization to schedule between 40 and 60 hours per week, lives in the same home with the PCA, and has no other PCA; or 2) the consumer requires an individual PCA to work more than 40 hours per week to maintain continuity of care while the consumer seeks and hires additional PCAs. A PCA may not work more than 40 hours per week for a consumer unless the consumer is approved to schedule the PCA for overtime hours. If a PCA works for more than one consumer, the PCA may not work more than 40 hours per week in total for all consumers unless one or more of the PCA’s consumers is approved to schedule the PCA for overtime hours.

Penalties

Under the revised regulation, MassHealth may impose sanctions, including termination or suspension of PCA participation in MassHealth, for any violation by the PCA of the weekly hour limits set by the regulation. Additionally, MassHealth reserves the right to recover costs of overtime from the member for any overtime scheduled by a member and performed by an individual PCA in excess of the overtime hours as approved by MassHealth.

Questions

If you have any questions about the information in this transmittal letter, please contact the MassHealth Customer Service Center at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.

See the full Transmittal letter including regulation updates at  http://www.mass.gov/eohhs/docs/masshealth/transletters-2016/pca-21.pdf

Effective July 1, 2016, MassHealth issued a new Medical Necessity Form (MNF) that must be completed by appropriate medical staff prior to the state covering the costs of certain non-emergency medical transportation for MassHealth members. This applies to transportation provided by ambulance providers and chair cars and does NOT apply to services approved through the Prescription for Transportation (PT-1) process.

The ambulance provider is required to ensure the form is completed; they may require the authorizing medical provider to complete parts of the form prior to their agreeing to and authorizing non-emergency medical transportation for MassHealth members. 

See the medical necessity form.

Additional information provided by MassHealth can be found in this Transportation Bulletin 16, provided in June 2016.
The MassHealth-issued Medical Necessity Forms (MNFs) will constitute valid authorization for:

• Non-emergency wheelchair van transportation provided to MassHealth members who reside in institutional settings;
• Non-emergency wheelchair van transportation provided to MassHealth members who reside in the community and need mobility assistance from transportation provider personnel to exit their residences or to move from their residences to the vehicle;  
• Non-emergency ambulance transportation provided to any MassHealth member, regardless of where the member resides; or
• Please note that MassHealth is also now providing non-emergency transport for members, who are being discharged from a psychiatric hospital to a community-based setting, and require supervision during transportation. This benefit is for patients receiving detox or other substance use disorder services whose best interest is to have transportation take them directly to the community-based setting from the hospital. However, please note that the Prescription for Transportation (PT-1) form that authorizes coverage for community-based transportation services is not the appropriate form for such services.

As indicated on the MNF, any of the following providers are authorized to complete and sign the MNF to request transportation:

• Dentist
• Managed Care Representative
• Nurse Midwife
• Nurse Practitioner
• Physician
• Physician Assistant
• Physician Designee (Registered Nurse)
• Psychologist

For Dual Eligibles- Two Forms Now Required

For Medicare and Medicaid dual eligible members, providers should be aware that two documents will be needed to determine the medical necessity of the transport – 1) a Medicare Physician Certification Statement and 2) the MassHealth MNF as outlined above.  
The Physician Certification Statement is a Medicare required form.  Under Medicare requirements, for there to be coverage of a non-emergency transportation, the beneficiary’s attending physician must sign the Physician Certification Statement that documents the medically reasonable and necessary basis for using the ground ambulance (ALS, BLS, wheelchair van) that meets the following requirements:

• Due to the beneficiary’s condition, the use of any other method of transportation is contraindicated; and
• The purpose of the transport is to obtain a Medicare-covered service or to return from obtaining such service.

-Thanks to Brooke Alexander, Public Payer Patient Access, Partners Community Health, for sharing this update from the Mass. Hospital Association, and her assistance with this article.

In January, EOHHS announced plans to implement a Managed Care lock-in policy effective October 1, 2016.  This would restrict the ability of MassHealth members to freely change managed care plans. Despite opposition from most consumer, legal aid and disability rights groups, EOHHS is moving ahead to implement this change. 

Proposed rules are posted on the MassHealth website with a publication date of July 20, 2016.  A public hearing is scheduled for Wed. August 10 at 10 am in Boston. Written comments are also due by 5 pm August 10. 

The public notice, proposed rules, current rules, & a link to sign up to testify are all posted at 
http://www.mass.gov/eohhs/gov/laws-regs/masshealth/masshealth-proposed-regs.html

Current  transfer rule

The current rules at 508.002(E) allow MassHealth members to transfer between MCOs or MCOs and the PCCPlan at any time. The only restriction is for people in CarePlus whose transfers take effect on the first of the following month unless the transfer is "for cause" in which case the transfer happens right away.  The rule  lists 4 kinds of cause. 

Proposed MCO transfer rule

Under the proposed MCO rule 508.004(C): MassHealth members can transfer freely as they do now only during a "plan selection period." This is a 90-day period that for new members begins with enrolling into an MCO and for continuing members will be during an annual 90 day period announced by MassHealth. 

Any time outside this 90 day "plan selection period" is a "fixed enrollment period" during which MassHealth members can switch plans only "for cause" as determined by MassHealth.

This is not an open enrollment period like the one in ConnectorCare. MassHealth members can still apply and enroll at any time. 

Proposed PCC transfer rule (no change)

The current rules stays the same for the PCC Plan. Proposed 508.005(C). People in the PCC Plan can transfer out to an MCO at any time, but then will be locked into the MCO.

Proposed changes to services needing a PCCP referral

There are also changes to the PCC Plan referral rules in 130 CMR 450 the Administrative and Billing rules. 

The referral rules at 130 CMR 450.118(J) currently say that people enrolled in the PCC Plan need to get a referral from their PCC to see any other providers except for those listed below in the rule.  The Proposal removes some services from the "no referral" list; this means MassHealth members will need to ask their PCC for a referral for these services. This proposal is not eliminating services from the PCC Plan --the Administration has threatened to do just that in October 2017 --but right now the only change is to require a PCC referral for services that currently do not require a referral including orthotics, prosthetics, hearing aids and chiropractic services. 

The public notice, proposed rules, current rules, & a link to sign up to testify are all posted at 
http://www.mass.gov/eohhs/gov/laws-regs/masshealth/masshealth-proposed-regs.html

-From Vicky Pulos, Mass Law Reform Institute, July 19, 2016.

The state's Medicaid office improperly paid over $15 million in taxpayer dollars for programs that aid disabled adults, according to a report issued by State Auditor Suzanne Bump.

Bump's investigators concluded that between 2010 and 2015, MassHealth, the state agency that distributes federal Medicaid services in Massachusetts, paid out $15,201,854 for duplicate adult foster health care services for patients already in long-term care facilities that provide similar services.

MassHealth disagrees with Bump's findings. The agency claims that rest homes for the elderly, one of several categories of long-term facility analyzed by Bump and her team, are not covered by Medicaid and therefore patients residing in them are eligible for additional state care.

"While they provide protective housing environments for the elderly, they do not provide the same level of medically necessary assistance ... that is provided under the [group adult foster care] program," MassHealth responded to Bump.

Bump disagrees with MassHealth's assessment that rest homes are covered under adult foster-care regulations.

"Our audit work showed that rest-home services and GAFC services were essentially identical and resulted in duplicative payments of more than $15 million by the Commonwealth," she wrote in response.

In 2013, MassHealth issued a letter to their contracted adult foster-care providers saying that despite those regulations, they would continue to pay for group foster-care services for patients already receiving them and living in long-term facilities.

Bump said the team was initially investigating possible fraud by the recipients of the care while in rest homes when they found it was MassHealth policies that allowed it to happen. Bump says what seems to be happening is that MassHealth services are being used to supplement the staffs of the rest homes where the improper services are happened.

-See the full WGBH story.

People fighting addiction who get subsidized insurance will no longer have to pay for outpatient medication and counseling starting next year, a move officials hope will reverberate throughout the insurance market.

The Massachusetts Health Connector, a state agency serving people who don’t obtain insurance through an employer, is requiring Connector insurers to eliminate all out-of-pocket costs for medication-assisted treatment that includes drugs such as methadone or Suboxone along with counseling.

The requirement applies only to health plans that come with federal and state subsidies, which together enroll 169,000 people, a small fraction of the 4.2 million Massachusetts residents who buy commercial insurance.

The Connector developed the requirement for its 2017 plans to bolster the state’s campaign against opioid addiction, said Ashley Hague, deputy executive director.

Vic DiGravio, president of the Association for Behavioral Healthcare, said the out-of-pocket costs for counseling, a critical aspect of medication-assisted treatment, are often prohibitive for low-income people. Many methadone patients, for example, have seven counseling sessions a week.

The new rules also eliminate out-of-pocket costs for Narcan and other drugs that reverse overdoses.

Most people who get insurance through the Connector receive a subsidy to help them pay their premiums. Those subsidized plans, called ConnectorCare, don’t have deductibles, but they do have copays for some services. The change eliminates copayments for medication-assisted treatment.

Clinical Stabilization Services

The Connector is also trying to improve access to another addiction service: clinical stabilization services, which are residential programs where people go to continue their recovery after they have finished detox treatment. A 2014 state law requires insurers to cover these services, but patients are not always able to find them close to home.

ConnectorCare plans will now have to make “a good faith effort” to offer a contract to every clinical stabilization service provider in their coverage areas.

-See the full Boston Globe article.

Brookings Institution’s Stuart Butler: “Given the cost of health insurance, prescriptions, and deductibles, few Americans would be surprised to learn that we spend a much higher proportion of our economy on healthcare than other major countries. The major European countries, for instance, spend between about 9 and 12 percent of their GDP on health services. We spend more than 17 percent.”

“But despite this heavy investment in medical services, we actually have similar or worse outcomes on several key measures of health, such as infant mortality and the prevalence of chronic diseases. So why do we get so little when we spend so much?”

“A clue comes from the balance of spending in America between medical services and social services, including such things as housing assistance, food aid, and child support. Medical experts are increasingly coming to the conclusion that improving these ‘social determinants’ often results in better long-term health than does intensive and expensive medical care.”

“The US is very much the outlier on spending devoted to social services compared with medical care. The major (OECD) countries on average spend about $1.70 on social services for each $1 on health services. But the US spends just 56 cents per health dollar. Yet research shows that basic measures of health in countries are more closely and positively associated with social service spending than with health spending.”

-From Wonkwire.com

It would be foolish to expect an addict - straight out of jail, treatment, or both - to find a sober night’s sleep under a bridge, said Jared Owen, a man in recovery.

This month public and private sector leaders from across New England and upstate New York convened in Boston to talk about substance abuse in their states, and how comprehensive housing programs could help curb the crisis.

Marylou Sudders, the state’s secretary of health and human services, called for an increased focus in Massachusetts on supportive housing programs, which combine affordable housing and services that help smooth recovery process.

“We need to focus more on the path to recovery, which is really bringing together housing and treatment and employment,” Sudders said. “One of the biggest challenges for individuals . . . is finding a safe, drug-free environment to recover in.”

Sudders told the crowd of about 60 New England public health officials that comprehensive housing should be at the forefront of the battle against opioid abuse, which has ravaged Massachusetts, claiming the lives of an average of four residents a day.

According to the Corporation for Supportive Housing, the nonprofit that hosted the event, homeless adults between the ages of 25 and 44 in New England were nine times more likely to die from an overdose than those with stable housing.

Sudders said jails and the streets are too often the primary living option for adults struggling with addiction.

-See the full Boston Globe article.

The Affordable Care Act opened the door for millions of young adults to stay on their parents' health insurance until they turn 26. But there's a downside to remaining on the family plan.

Chances are that Mom or Dad, as policyholder, will get a notice from the insurer every time the grown-up kid gets medical care, a breach of privacy that many young people may find unwelcome.

With this in mind, in recent years a handful of states have adopted laws or regulations that make it easier for dependents to keep medical communications confidential.

The privacy issue has long been recognized as important, particularly in the case of a woman who might fear reprisal if, for example, her husband learned she was using birth control against his wishes. But now the needs of adult children are also getting attention.

Federal law does offer some protections, but they are incomplete, privacy advocates say. The Health Insurance Portability and Accountability Act of 1996 is a key federal privacy law that established rules for when insurers, doctors, hospitals and others may disclose individuals' personal health information. HIPAA contains a privacy rule that allows people to request that their providers or health plan restrict the disclosure of information about their health or treatment. People can ask that their insurer not send to their parents the ubiquitous "explanation of benefits" form describing care received or denied, for example. But an insurer isn't obligated to honor that request.

In addition, HIPAA's privacy rule says that people can ask that their health plan communicate with them at an alternate location or by using a method other than the one it usually employs. Someone might ask that EOBs be sent by email rather than by mail, for example, or to a different address than that of the policyholder. The insurer has to accommodate those requests if the person says that disclosing the information would endanger them.

Concerns by young people that their parents may find out about their medical care leads some to forgo the care altogether, while others go to free or low-cost clinics for reproductive and sexual health services, for example, and skip using their insurance. In 2014, 14 percent of people who received family planning services funded under the federal government's Title X program for low-income individuals had private health insurance coverage, according to the National Family Planning and Reproductive Health Association.

Even though most states don't require it, some insurers may accommodate confidentiality requests, said Dania Palanker, senior counsel for health and reproductive rights at the National Women's Law Center, a research and advocacy group.

"Inquire whether there will be information sent and whether there's a way to have it sent elsewhere," Palanker said. "It may be possible that the insurer has a process even if the state doesn't have a law."

-See the full NPR/Kaiser Health News story.

Decades of societal and cultural misunderstanding leave mental health shrouded in judgment, infused with moral disapprobation, and in many ways generally viewed as a character failure. Despite substantial advances in our scientific understanding of mental health over the years, there remains a disconnect between evidence and public perception, a disconnect even between the science and clinicians. Efforts to normalize how mental health is seen in the public often take the form of public education campaigns aimed to destigmatize mental health, and attempt to usher in a new understanding of health, inclusive of mental health.

Stigma and discrimination reduction campaigns around mental health have had mixed results. Stigma reduction may help normalize mental, emotional, and behavioral health problems. Many stigma reduction campaigns aim to improve knowledge of mental health, educate the audience about the biological basis for mental illness, and help people feel more comfortable interacting with those experiencing mental health problems. Often, attempts are made to make mental, emotional, and behavioral health analogous to physical health issues. The person suffering mental illness, emotional distress, or behavioral health problems has done nothing to deserve their illness, nothing to cause their illness, and is not personally responsible for having acquired their illness.

There is growing evidence that educational stigma reduction programs that focus on the biological basis for mental illness can create the belief that it is intractable or reinforce the belief that the illness or a behavior problem is “hard-wired” and not amenable to treatment. Others have found that, while participants may know more about mental illness, they acquire more negative attitudes towards those with mental illness, and are more likely to avoid those with mental and behavioral health problems.

Stigma reduction programs may be crowding out space in the conversation for prevention of mental, emotional, and behavioral health problems. The idea that mental illness is biologically based, “hard-wired,” genetic, suggests there may be nothing we can do to prevent it. However, prevention is possible.

Consider the 2009 report by the Institute of Medicine. In this report, there are concrete and actionable steps to help prevent mental, emotional, and behavioral problems in children. Examples include strategies on offering early intervention for families and individuals and promoting mental health treatment in schools and community programs. It is possible to prevent the illness as well as treat and minimize the dysfunction that may accompany mental illness.

How We Can Prevent Behavioral Health Problems

How might we actually prevent mental, emotional, and behavioral health problems? Alexander Leighton, in his ground-breaking work My Name Is Legion, on mental illness and the community, wrote that some mental, emotional, and behavioral health problems are associated with, and may be caused by human susceptibility to our community environment. It is not an individual’s fault they acquire a mental illness, nor is it always hard-wired into their DNA that they will manifest mental illness or emotional distress. Community factors may have more influence on mental illness than we currently appreciate.

-See the full HealthAffairs Blog post.