In this issue:
By: Daniel Chang, email@example.com
The Miami Herald's article discussing the Public Charge Rule highlights FHJP's research analyzing the rule's impact in causing children to lose critical benefits, including health coverage and SNAP. The article also features Dr. Fred Anderson, FHJP Board member, discussing how the proposed rule changes are adding to immigrants' fears and raising the likelihood that their medical conditions will worsen.
Advocates Condemn Trump Administration’s Latest Attack on Immigrant Families
For Immediate Release: October 5, 2018
Contact: Matt Childers, firstname.lastname@example.org
Miami, Florida — The Trump administration moved forward this morning with plans to fundamentally alter how immigration officials determine what constitutes a “public charge,” which could result in denial of lawful permanent residence or entry to the U.S. At 8:50 a.m. the administration posted the new rule for “public inspection” and announced that the rule will be formally published in the Federal Register on October 10. This will commence a 60-day public comment period ending December 10, 2018.
The proposed rule, as with the draft released on Sept 22, 2018 , radically alters a 100-plus year old immigration law by significantly expanding the types of public benefits that could be included in a public charge determination. For decades, the only benefits that could be considered were cash assistance or long term institutional care. No other benefits could be part of the calculation. Under the new rule, health care benefits including Medicaid and Medicare low income subsidies for Part D (prescription drugs), housing assistance housing or Section 8 and Supplemental Nutrition Assistance Program (SNAP or food stamps) could be considered. Also, the new rule, for the first time, adopts a new income test for households to overcome a public charge test.
(Miami) - A draconian proposal by the Trump administration to overhaul how immigration officials determine what constitutes a “public charge” (which could result in denial of lawful permanent residence or entry to the U.S.) was announced on Saturday night. There will be a 60 day public comment period.
The proposed new rule radically revamps longstanding immigration law. For the first time, immigration officials could consider use of critical non-cash benefits intended to safeguard the health, nutrition, housing and economic security of America's low-income families in making public charge determinations. States with large immigrant populations like Florida will be disproportionately impacted.
Miriam Harmatz, Co-executive Director of the Florida Health Justice Project, explained that this represents a major shift from long-standing policy in which the only benefits considered in a public charge determination are cash assistance or long-term institutional care. "The chilling effect will result in Florida’s families and children being poorer and sicker.”
Local public officials across the country have been speaking out against the long rumored rule, and the Miami-Dade County Board of County Commissioners passed a resolution on 9/5/18 urging the federal government to maintain the status quo. Citing data provided by Dr. Matt Childers, Director of Policy Research for the Florida Health Justice Project, the Commission’s Resolution opposed any federal regulatory change that would negatively impact immigrant families.
In observing that “this is a disgraceful attack on immigrants legally living and working in our communities,” Maria Rodriguez, Executive Director of Florida Immigrant Coalition, also noted that nothing changes until the Administration reviews and responds to public comments. She urged all members of the public to submit comments. “This is an attack on the entire community.”
Jonathan Fried, Director of WeCount, similarly decried the proposal’s impact. “Key sectors of Florida’s economy, including agriculture and tourism, are dependent on immigrant workers who earn less than a living wage. Their families will forego Medicaid, food stamps, and housing assistance - services to which they are legally entitled - jeopardizing their health, safety and security, as well as Florida’s economic sustainability."
For more information on the rule’s impact in Florida and how to submit comments, contact Matt Childers.
Justice In Aging issues Press Release on the Advocate's Guide to the Florida Long Term Care Medicaid Waiver
Medicaid is critical for low-income Florida seniors, particularly those who can no longer live independently and need help at home. Unfortunately, seniors and people with disabilities often have difficulty getting the long-term services and supports they need to remain living at home and in the community.
The Florida Health Justice Project and Legal Services of Greater Miami Inc., with technical support from Justice in Aging, have created a new guide for advocates to help seniors access home and community-based services through Florida Medicaid’s long-term care waiver. Florida Medicaid covers “home and community-based services” that are not typically available through Medicare or private insurance, such as personal-care aides and private-duty nursing, for over 100,000 Floridians. However, more than 50,000 low-income Floridians are currently on a waiting list for these services.
The Advocate's Guide to the Florida Long Term-Care Medicaid Waiveris a roadmap to navigating eligibility and access to long-term services and supports that enable seniors to age at home and in the community rather than in nursing facilities. The guide provides an overview of the authority governing Florida's Medicaid long-term care waiver and addresses basic questions including:
Florida Health Justice Project issues Advocate's Guide to the Florida Long-Term Care Medicaid Waiver
Miriam Harmatz, J.D., Co-Director
Florida Health Justice Project
Office: (786) 558-4950
Cell: (786) 853-9385
(MIAMI) – Government-subsidized health-care benefits are critical for low-income Florida seniors – particularly those who are frail and disabled – but they can be hard to come by, which is why attorneys at the nonprofit Florida Health Justice Project (FHJP)and Legal Services of Greater Miami Inc. have published a guide for those advocates engaged in helping seniors access long-term care and related services under Florida Medicaid.
The Advocate's Guide to the Florida Long Term Care Medicaid Waiver, made available online thanks to the Florida Justice Technology Center (FJTC), concerns long-term services and supports that are essential to remaining at home or in the community rather than in a nursing home.
“For Florida seniors who want to stay out of a nursing home after they can no longer handle the routines of daily living, these services are critical, but like many Medicaid services, navigating the system is complicated,” said Miriam Harmatz, co-director of the Florida Health Justice Project, a new nonprofit advocacy organization. Earlier this year, the project prepared The Advocate’s Guide to the Florida Medicaid Program.
“These guides exemplify our mission and work,” Harmatz said. “Through collaboration with local legal services programs, FJTC and national partners, including Justice in Aging, we’re providing valuable resources for Florida’s legal aid and pro bono advocates who are helping clients get medically necessary services.” This is the second such collaboration between FHJP and FJTC.
As with The Advocate’s Guide to the Florida Medicaid Program, FJTC took the lead on dissemination by turning both guides into online, interactive versions.
“The advocate community plays such an important role in expanding access to justice, because they’re typically the ones advising and assisting those in need,” FJTC Project Manager Joseph Schieffer said. “We wanted to create something that would amplify their work and streamline the process to find information. Having the guide online makes it easier for advocates to navigate the content and share it with others.”
Long-term care – including both nursing home and community-based care – are both part of Florida Medicaid’s Long-Term Care Program. The new guide, however, focuses exclusively on the part of the program for those living at home or in the community, which falls under Florida Medicaid’s long-term care “waiver.” Under federal law, waivers allow states to provide home and community support services to a set number of people as an alternative to institutional care.
Also known as “home and community-based services,” the covered services are not typically available through Medicare or standard medical insurance, such as personal-care aides and private-duty nursing.
Nationwide, over half of people turning 65 will at some point develop a severe disability or medical condition that will require home and community-based services. Over 100,000 Floridians currently receive services through Florida Medicaid’s long-term care waiver, with over 50,000 on a waiting list.
The guide provides advocates with an overview of the authority governing Florida's Medicaid managed care long-term care waiver and a roadmap addressing basic questions including:
Jocelyn Armand, Legal Services of Greater Miami advocacy director, co-authored the guide with Harmatz, Katy DeBriere, co-director of the Florida Health Justice Project, and Michelle Adams, research assistant.
"The Advocate’s Guide is a much-needed resource for advocates and consumers alike. The guide’s road map helps navigate one of the most complex parts of the Medicaid program. We are extremely appreciative to the Florida Health Justice Project for the opportunity to collaborate on this crucial endeavor,” Armand said.
Anne Swerlick, health policy analyst with the Florida Policy Institute, endorsed the guide.
“This guide is an invaluable tool for Florida advocates seeking to ensure that consumer protection policies are implemented to protect Florida’s frailest residents,” Swerlick said.
Pro bono technical support for the guide also came from other groups, including Justice in Aging, a national organization that uses the power of law to fight senior poverty by securing access to affordable health care, economic security, and the courts for older adults with limited resources.
About the Florida Health Justice Project
A new nonprofit advocacy organization, the Florida Health Justice Project seeks to improve access to affordable health care for Floridians, with a focus on vulnerable low-income populations. FHJP expands the advocacy community’s capacity to resolve individual access issues and educate consumers; identify and address systemic barriers to healthcare; and protect Medicaid and other safety-net programs.
Florida Health Justice Project publishes article in the Florida Bar Health Law Section Newsletter explaining Florida's proposal to eliminate retroactive Medicaid eligibility (See story at page 4)
Florida Health Justice Project files comments opposing Mississippi's request to implement work requirements
In our first newsletter, we highlight what we're working on:
Proposed Changes To the Public Charge Rule Will Cause Significant Loss of Health Care Coverage for Florida Children
Pursuant to a draft rule now being considered by the Trump Administration, the federal government would, for the first time, consider use of virtually any publicly funded benefit intended to safeguard the health, nutrition, housing and economic security of America's low income families in making public charge determinations. The range of benefits that could be considered would include Medicaid, CHIP, marketplace subsidies, SSI, state and local government cash assistance programs, public assistance for long- and short-term institutionalized care, state and local subsidized health insurance, WIC, SNAP, LIHEAP, transportation vouchers, public housing assistance, and educational benefits like Head Start.
This represents a major shift from long standing policy in which the only benefits considered in a public charge determination (which could result in denial of lawful permanent residence or entry to the U.S.) are cash assistance or long term institutional care. The Administration's stated intent is to “provide a strong disincentive for the receipt or use of public benefits by aliens, as well as their household members, including U.S. children.”
This brief estimates the potential loss of one particular benefit on a single subset of the potentially impacted Florida population-- citizen children in Florida currently enrolled in Medicaid/CHIP.
Decreased Enrollment in Medicaid/ CHIP Among Florida’s eligible children.
Lawfully present immigrants eligible for Medicaid or CHIP, as well as US citizen children with one or more immigrant parents, are already far more likely to be uninsured than those without immigrant family members based on currently (unfounded) fears of negative immigration consequences. If the draft rule goes forward, this disparity will grow as the new rule explicitly intends to have a chilling impact. The implications for loss of coverage among Florida's children--particularly in South Florida-- are significant. The universe of those impacted is larger than the data provided in this brief because, among other things, significant numbers of eligible children are not currently enrolled, and, as a result of the new rule, their parents will likely not pursue enrollment.
There are currently over 400,000 Florida citizen children enrolled in Medicaid or CHIP with a non-citizen parent. As illustrated in the graph below, half of them live in the Miami metropolitan area which includes: Miami-Dade, Broward, and Palm Beach Counties.
If the rate of disenrollment ranges from 15 to 35% among these families, between 46,000 and 107,000 children will lose insurance in Florida overall.
Note: The number of citizen children whose coverage would be adversely impacted under the draft rule is significantly higher than the data above since this analysis does not include an estimate of the children who are currently eligible but not enrolled.
For more information, please visit the Protecting Immigrant Families website. If you have any questions about the public charge rule, please contact Miriam Harmatz, email@example.com. If you would like more information about our methodology, please contact Matt Childers, Ph.D., at firstname.lastname@example.org.
Click here to download a copy of this brief.
Aging Today Features Our Board Member Paul Nathanson For His Decades of Legal Advocacy On Behalf of Older Adults
Leaked policy proposals, including to the long standing public charge rule, indicate the Administration’s intent to make life more difficult for immigrants, including their U.S. citizen children, by restricting their ability to access basic programs safeguarding the health care, nutrition, housing, and economic security of low-income families.
The Florida Health Justice Project is part of a national Protecting Immigrant Families Campaign bringing together local, state and national advocates to defend against these threats through outreach and education. The public, press and policy makers need to understand the harmful impact such changes would have on Florida’s families and communities.
The resources below provide Information and data on the public charge issue and include materials for Florida's health care providers, immigrant advocates and impacted individuals willing to share their stories. It is vitally important that we hear from you.
Written by Joan Alker and published by the Center for Children and Families. Reposted here with their permission.
The Children’s Health Insurance Program (CHIP) is extremely important to Florida as it helps about 345,000 Florida children get the health care they need to support their healthy development and succeed in school.
CHIP has also worked hand-in-hand with Medicaid to reduce Florida’s child uninsured rate to an all time low of 6.2 percent in 2016. This is still higher than the national rate of 4.5 percent.
The new federal CHIP law was good news for Florida’s children as it should protect their access to affordable health coverage for the next decade.
This week we released a report and hosted a webinar with the Health Affinity funders of the Florida Philanthropic Network on how the new CHIP law will work for Florida children and families.
The new law would:
In Florida, CHIP funds coverage for children in families of three earning up to about $3,723 per month. Florida uses federal CHIP funding to operate three programs: MediKids, Healthy Kids and the Children’s Medical Services Managed Care Plan. The CHIP matching funds are also supporting lawfully residing immigrant children in both Medicaid and CHIP.
The report is the second in a series of reports on CHIP recently published by Georgetown University CCF and the Health Affinity Funders of the Florida Philanthropic Network.
Joan Alker is the executive director of the Georgetown University Center for Children and Families and a research professor at the Georgetown University McCourt School of Public Policy. She is a nationally recognized expert on Medicaid and CHIP and has conducted extensive research and analysis on Florida’s public health coverage programs.
Florida Health Justice Project files comments opposing the Administration's changes to the Medicaid "equal access rule" that would erode access to Medicaid services
Florida Health Justice Project Issues Comprehensive Guide to State’s Medicaid Law
Washington – Multiple court decisions have quoted the late federal Judge Henry Friendly's observation that Medicaid law is “almost unintelligible to the uninitiated.” And while states must follow federal Medicaid law, each state program has its own policies and procedures. In response to this challenge, the National Health Law Program prepared a template guide that state advocates could to use in creating state specific Guides.
Based on the National Health Law Program’s template, the newly published Advocate’s Guide to the Florida Medicaid Program provides an overview of who in Florida is eligible for Medicaid; how to apply; what to do if an application or services are denied or delayed; and how the Florida Medicaid managed care program works.
In addition to providing a basic roadmap for obtaining Medicaid eligibility, the Guide provides Florida advocates with citations to the underlying statutes, regulations, policies, and managed care contracts if clients experience denials or delays.
With financial support from the Florida Justice Technology Center (FHTC), the Guide was prepared by Miriam Harmatz, Co-Director of the new the Florida Health Justice Project(FHJP), along with co-authors Margaret Kosyk of Coast to Coast Legal Aid of South Florida, Inc., and Jazmine-Janine Dykes, a third-year law student at the University of Miami Law School.
Harmatz said, “The Guide exemplifies FHJP’s mission, i.e. increasing the advocacy community’s capacity to ensure access to health care for low income Floridians, and we are deeply grateful to FJTC and NHeLP for their support.”
National Health Law Program Managing Attorney of the North Carolina office Sarah Somers said the Florida guide would be indispensable to health care advocates in the state.
“Medicaid is a vital health care program, especially for women, people of color, and low-income individuals and families,” Somers said. “The Advocate’s Guide to the Florida Medicaid Program is accessible and will prove integral to the advocates who work every day to ensure that Floridians struggling to make ends meet are not denied access to quality health care.”
Somers added, "We also look forward to working with FHJP on updating the Advocate’s Guide to the Florida Medicaid Program, if and when Florida decides to join 32 states and the District of Columbia in accepting federal dollars to extend Medicaid coverage to all low income adults as set forth in the Affordable Care Act. For that to happen we must forcefully counter the cruel and antiquated argument that low income people have to be ‘worthy,’ which really means only those who are aged, blind, disabled, a child, are provided affordable health insurance plans.”
Read the Florida Medicaid program guide here.
Please contact the National Health Law Program Communications Department at email@example.com or 202-552-5176 to speak with Harmatz or Somers about the new Florida Medicaid guide.
National Health Law Program, founded in 1969, advocates for the rights of low-income and underserved people to access quality health care.
The 24-page guide summarizes the legal governance of a complex and frequently changing federal-state insurance program that covers medical expenses for eligible families, pregnant women, elderly and disabled individuals and others. An additional 10 pages contain 128 specific legal citations.
“The guide addresses basic questions asked by advocates, applicants and beneficiaries,” said Miriam Harmatz, co-director of the new Florida Health Justice Project, who co-authored the guide with Margaret Kosyk of Coast to Coast Legal Aid of South Florida Inc. and Jazmine-Janine Dykes, a third-year law student at the University of Miami School of Law.
Among the questions the guide answers are: who is eligible for Medicaid; how to apply; what to do if an application is denied or delayed; what to do if eligibility is terminated; what services are covered; how managed care works; and what to do if a beneficiary’s services are denied, delayed, terminated or reduced.
In addition to providing a basic roadmap for obtaining Medicaid eligibility and/or services, the guide, which will be regularly updated, provides Florida advocates with citations to the underlying law and relevant policies in the event their clients experience denials or delays.
“The Advocate’s Guide is a wonderful resource for health-law advocates in legal services programs, as well as for pro bono attorneys working in this complex area of the law,” said Barbara J. Prager, executive director of Coast to Coast Legal Aid of South Florida Inc.
The new Florida guide is one of the first of its kind in the nation and is based on a template created by the National Health Law Program (NHeLP) for use in creating state-specific guides. It was produced with financial support from the Florida Justice Technology Center (FJTC), a nonprofit corporation established to increase access to justice through the innovative use of technology.
“The guide exemplifies the mission of the Florida Health Justice Project, which is to increase the advocacy community’s capacity to ensure access to health care for low-income Floridians,” Harmatz said. “We are deeply grateful to both FJTC for their financial support and to NHeLP for sharing their expert support and materials, including a template guide. It would not have been possible without them.”
The Advocate’s Guide to the Florida Medicaid Program is available at https://www.floridahealthjustice.org/medicaid-guide.
About the Florida Health Justice Project
A new nonprofit advocacy organization, the Florida Health Justice Project seeks to improve access to affordable health care for Floridians, with a focus on vulnerable low-income populations. FHJP expands the advocacy community’s capacity to resolve individual access issues and educate consumers; identify and address systemic barriers to healthcare; and protect Medicaid and other safety-net programs.
First, a “thank you”to those responsible for the recent Global Health Equity Symposium at Carrolton School of the Sacred Heart in Miami. They gave everyone present the precious gift of inspiration. Part of the gift was no doubt due to the setting-- an iconic old school on Biscayne Bay where nature and buildings blend to make the other even more beautiful. And “credit where credit’s due:” the Symposium coincided with 3 days of perfect 70 degree weather and brilliant blue sky.
The event began with a documentary about the work of Partners in Health (PIH), Bending the Arc. If you’ve not heard of PIH or the co-founder, Dr. Paul Farmer, and you care about social justice and access to health care, you should read one of Farmer’s books or speeches or, better yet, see the movie. Famer has touched and saved countless lives, helped transform the health care systems of some the world’s poorest nations; co-founded one of the most profoundly positive and impactful non-profits in the history of nonprofits; spoken truth to power. Perhaps most inspiring…. he’s humble and collaborative.
A quick background on how the Symposium happened: Laurie Weiss Nuell, a Miami native whose family has long supported health care equity in Miami and around the world, suggested to Dr. Farmer that he collaborate with Patti Wiesen. Patti is a Carrolton teacher who shares their passion for social justice and imparts it to her students through her art classes, (scroll to bottom of homepage for a short video that tells symposium’s history. http://globalhealthequity.net.)
After the movie, in response to a question about Miami’s health disparities, Dr. Farmer said global health equity is not just about “far away problems;” that working on health justice in the states means focusing on legislation, and that this effort requires some understanding of the economics and financing of health care in America.
So, thank you Dr. Farmer for the perfect segue to a breakout session I led the next day on the moral and economic issues in Florida’s Medicaid expansion debate. Florida is one of 19 states that has still not extended health care coverage to low-income uninsured adults under the Affordable Care Act. As a result, over half a million Floridians have no path to affordable health care and Florida is leaving over $ 5 billion of federal funds per year on the table. We talked about how people (and our local economies) are suffering unnecessarily and how students, faculty and others can work with advocates, including the new Florida Health Justice Project, www.floridahealthjustice.org., on expanding Medicaid.
We talked about how Florida’s Medicaid expansion fight is similar to PIH’s struggle—both are about health care access for poor people who don’t have it. But compared to the monumental efforts of PIH in Haiti, South American and Africa-- where MOUNTAINS have been moved-- the struggle here is like moving a molehill. There are many of us in Florida to move that molehill; we don’t have to get on a plane, we can bend the arc at home.
By Miriam Harmatz, Co-Executive Director
Florida Health Justice Project's Public Comments Opposing the Florida AHCA's Proposal to Waive Medicaid's Three Month Retroactive Eligibility Period
Justin Senior, Secretary
Agency for Health Care Administration
2727 Mahan Drive, MS #20
Tallahassee, FL 32308
Submitted via email: FLMedicaidWaivers@ahca.myflorida.com
Re: Proposed Amendment to Florida’s Medicaid 1115 MMA Amendment (Project Number 11-W-00206)
Dear Secretary Senior:
This comment letter is submitted on behalf of the Florida Health Justice Project (FHJP). Our mission is helping to ensure access to low income Floridians with a focus on vulnerable low-income populations.
The Agency for Health Care Administration’s (AHCA’s) proposal to waive the federal Medicaid statute’s provision allowing for up to three months of retroactive Medicaid eligibility (RME) will have adverse impacts on access to health care—particularly for seniors and adults with disabilities—some of the most vulnerable in the state. This proposal is contrary to the objectives of the Medicaid Act, it undermines the purpose of the RME provision passed by Congress, and it fails to meet requisite criteria for a Section 1115 Demonstration Waiver.
Retroactive Eligibility is a Critical Provision of the Medicaid Act
Under federal Medicaid law, costs incurred during the three months prior to the month of application can be reimbursed if: 1) they are covered under the Florida Medicaid plan; and 2) the beneficiary would have been eligible for Medicaid at the time the expenses are incurred.
The Legislative history related to this provision is highly relevant. Specifically, the three month retroactive period is meant to “protect persons who are eligible for Medicaid but do not apply for
assistance until they have received care, either because they did not know about Medicaid eligibility requirements or because the sudden nature of their illness prevented their applying.” HR. Rep. 92-231 (1972) reprinted in 1972 U.S.C.C.A.N. 4089, 5099.
In other words, Congress responded to the simple fact that no one can predict sudden illness or accident. After someone is in a hospital or nursing facility, she or he may not be healthy enough to file a Medicaid application or may not understand that a Medicaid application should be filed. Furthermore, the process of preparing a Medicaid application may take weeks. Elimination of RME puts unfair burden on elderly, ill, and disabled individuals and their families. Those who experience a catastrophic injury rendering them unable to apply quickly for Medicaid will be responsible for medical bills incurred during a period in which their bills are likely the highest. As a result, vulnerable low income Floridians will be at risk of incurring crushing financial stress and debt.
Additionally, the state’s care system for elderly and disabled Floridians, including safety net hospitals and nursing homes, depend on retroactive Medicaid. If the RME period is eliminated, these health care providers may be unable to provide essential but expensive care until a Medicaid application is filed and approved.
The proposal also fails to make any exception for low-income Medicare beneficiaries in Florida who qualify for the Specified Low-Income Medicare Beneficiary (SLMB) or Qualified Individual-1 (QI-1). These programs pay Medicare Part B premium ($134/month.) Eliminating retroactive coverage means that low income Medicare beneficiaries who qualify for SLMB or QI-1 but who did not apply concurrent with the month of their initial Medicare enrollment will lose about $400. This is a tremendous sum for these low-income individuals. In contrast, the state saves very little. Indeed, the federal government pays 100 percent of the cost for QI-1 eligible individuals so there is absolutely no state savings achieved through eliminating their RME for this population; the proposal only serves to hurt these low income seniors and persons with disabilities. Put another way, the state’s rationale for this proposal, “to enhance fiscal predictability” makes no sense for this group of these low-income Medicare beneficiaries. Again, for QI-1s, there are no state costs, and for SLMBs, the costs of retroactive eligibility for this group are predictable, i.e. a flat premium for three months of eligibility.
There is also a risk that the Department of Children’s & Families Economic Self Sufficiency staff (DCF-ESS) who process Medicaid applications will not receive adequate and timely training and oversight to correctly implement this change to the RME eligibility period. For example, staff may conflate the concept of a “retroactive period” with the federal and state requirement that Medicaid eligibility begins in the month of application (as opposed to the month of approval). As previously mentioned, the individuals impacted by Florida’s effort to shorten the RME period include those with disabilities, and their Medicaid application processing period is generally at least ninety days. If DCF-ESS staff misunderstand or misapply the change, these individuals could lose additional months of eligibility to which they are lawfully entitled in addition to elimination of their RME period.
The Proposed Waiver Fails to Meet the Requirements of Section 1115
Under Section 1115 of the Social Security Act, states can submit a “waiver request” to the Secretary of HHS to waive some requirements of the Medicaid Act in order to test novel approaches” likely to assist in promoting the objectives [improving medical assistance for low income people]. This proposal fails to meet that standard. It not only fails to identify a specific proposition to be tested, it utterly undermines the objectives of the Medicaid Act by denying health care coverage to people who desperately need it. Waivers should be used to improve coverage, not to leave Medicaid eligible persons without coverage when they have health care needs, especially when those needs are unpredictable.
Also, while Section 1115 of the federal Medicaid Act allows HHS to temporarily waive certain requirements of the Act to experiment, pilot, or demonstrate the efficacy of a new approach to the administration of the Medicaid program, HHS can only waive requirements found within the provisions of 42 U.S.C. § 1396a. Although RME is referenced in §1396a of the Medicaid Act, it is separately defined in §1396d. In other words, the RME provision is not within the waiver authority of the Secretary because the provision lies outside of §1396a. There is also no evidence that it constitutes a ‘novel approach” that would “improve medical assistance for low income people” thereby belying the stated purpose of Section 1115.
Thank you for considering these comments. We urge AHCA to reconsider submitting this amendment as it contravenes the objectives of the Medicaid Act.
s/Miriam Harmatz, Katy DeBriere
Miriam Harmatz and Katy DeBriere
Florida Health Justice Project, Inc.
Center for Medicare Advocacy and Florida Health Justice Project Sue to Obtain “Off-label” Part D Prescription Drug Coverage for Beneficiary
FOR IMMEDIATE RELEASE
April 16, 2018
Center for Medicare Advocacy – Kata Kertesz: 202-293-5760, KKertesz@MedicareAdvocacy.org
Florida Health Justice Project – Miriam Harmatz: 786-853-9385, Harmatz@FloridaHealthJustice.org
On April 6, 2018 the Center for Medicare Advocacy and Florida Health Justice Project filed a lawsuit in the United States District Court for the Southern District of Florida on behalf of a 49-year-old Florida resident seeking Medicare coverage for the “off-label” (non-FDAapproved) use of a critically needed medication (Dobson v. Azar, 4:18-cv-10038-JLK).
Donald Dobson needs Dronabinol to control his debilitating nausea and vomiting. His symptoms result from severe pain after multiple surgeries he required due to a workplace injury. After numerous medications failed to provide relief, Mr. Dobson’s doctor prescribed Dronabinol, which significantly relieved his nausea and vomiting and allowed him to resume many activities of a normal life. However, when Mr. Dobson became eligible for Medicare Part D, his plan denied coverage because his particular use of the medication is not FDA-approved. After exhausting Medicare’s appeal system, Mr. Dobson is now seeking help in federal court as his only hope to receive this critically important and medically necessary treatment for his debilitating symptoms.
Kata Kertesz, an attorney with the Center for Medicare Advocacy said, “The Medicare agency is using an overly narrow interpretation of the law to deny coverage of a drug that it does not dispute is medically necessary for Mr. Dobson. The doctor prescribed this medication because it is the only one that has worked to control Mr. Dobson’s symptoms. But, he cannot afford it without Medicare Part D coverage.”
Mr. Dobson’s Medicare Part D plan should cover the Dronabinol because his use of the drug is supported by one of the “compendia” of medically-accepted indications listed in the Medicare law. Medicare looks to the compendia for acceptable off-label uses of medications, and the symptoms of nausea and vomiting are listed in an entry for Dronabinol. “Mr. Dobson’s position is strongly supported by another recent federal case about a beneficiary who gained Part D coverage of the same medication for very similar symptoms,” said Ms. Kertesz. “However, the Medicare agency is using an inappropriately restrictive reading of the law to claim that coverage cannot be granted for Mr. Dobson.” (See, Tangney v. Burwell, 186 F. Supp. 3d 45 (D. Mass. 2016)).
Miriam Harmatz, Co-Executive Director of the Florida Health Justice Project, stated, “this is an important case, and we hope there will be a clear ruling by the court that’s consistent with Tangney and a Florida Medicaid case, Edmonds v. Levine, 417 F. Supp. 2d 1323 (S.D. Fla. 2006). This will both ensure that Mr. Dobson gets the medication he desperately needs, and help ensure appropriate application of the law governing off label uses in other cases.”
The Center for Medicare Advocacy (www.medicareadvocacy.org) is a national, nonprofit, non-partisan law organization that works to advance access to comprehensive Medicare coverage and quality health care for older people and people with disabilities through legal analysis, education, and advocacy.
The Florida Health Justice Project (www.floridahealthjustice.org) is a new Florida nonprofit that works to ensure access to necessary health care for low-income Floridians.
Paul Nathanson, A Founding Board Member of the Florida Health Justice Project, Receives ASA Hall of Fame Award
Justice in Aging is proud to announce that the American Society on Aging is honoring Paul Nathanson with its 2018 Hall of Fame Award. The award will be presented today at 4PM in the Continental Ballroom during the opening plenary of the American Society on Aging’s annual conference in San Francisco.
Paul is a two-time former Executive Director of Justice in Aging. He served from 1972-1980 as the organization’s first Executive Director and then returned to serve from 2008-2013 when Justice in Aging’s current Executive Director, Kevin Prindiville, assumed the role. Paul continues to work as special counsel where he contributes to Justice in Aging’s efforts to restore and improve the Supplemental Security Income Program (SSI).
The Hall of Fame Award is presented to an individual who has, through a lifetime of advocacy and leadership, enhanced the lives of elders through demonstrated leadership on the national level.
“Paul has been a wonderful mentor and colleague over the years. His work has been instrumental in several precedent-setting legal cases that have returned billions of dollars in benefits to low-income older adults who would otherwise have had no access to justice”, said Kevin Prindiville, Executive Director, Justice in Aging.”
"Paul Nathanson is an icon in the world of legal services and elder justice lawyers. We are fortunate that he is now living in Florida and continuing his advocacy leadership and support on behalf of low income seniors. as a founding board member of the Florida Health Justice Project",- Miriam Harmatz co-Exec Dir. FHJP
Please join us in congratulating Paul!
Florida Health Justice Project (FHJP) Opposes Medicaid Work Requirement in Florida
Joins leading health care, disability rights, faith-based housing and civil rights groups opposing a new federal policy now before the Florida legislature.
(Miami, Florida) - March 5, 2018 - The Florida Health Justice Project (FHJP) has joined 160 organizations, representing leading health care, disability rights, criminal justice, faith-based housing and civil rights groups, in opposing the new Centers for Medicare and Medicaid Services (CMS) policy that would allow Florida to impose work requirements on Medicaid recipients. (https://lac.org/wp-content/uploads/2018/02/february-2018-Medicaid-work-requirements-letter-to-Sec-Azar.pdf)
The Florida Senate is currently considering a bill (HB 751) that has already passed the Florida House which would require some Medicaid recipients to provide proof they are either working, attending school or searching for employment.
This policy would have a significant and disproportionately harmful impact on low-income individuals with chronic health conditions, especially those struggling with substance use disorders (SUDs) and mental health disorders.
“Floridians on Medicaid who can work are already working. This proposal is another cruel blow to residents who can’t work because of illness or drug addiction, and it makes no sense to cut off their access to healthcare,” said Florida Health Justice Project co-director Miriam Harmatz.
FHJP also agrees with lawyers from the National Health Law Program, the Kentucky Equal Justice Center and the Southern Poverty Law Center who recently challenged the legality of Kentucky’s work requirements.
“Moreover, the proposal would be especially egregious in Florida, which has yet to expand Medicaid,” Harmatz said. “The individuals who would lose coverage are mostly parents who have serious health issues. Without health care coverage, children, as well as parents will suffer.”
To speak with Miriam Harmatz, call 786-853-9385 or contact her at firstname.lastname@example.org
In past years, the Florida Legislature debated Medicaid expansion, the Senate passed expansion bills twice, and the state’s press corps-- given that they had something to “cover”—did a tremendous public service in helping Floridians better understand the costs and benefits of decreasing the state’s rate of uninsured. But for the last few years, health care policy debates have ignored Medicaid expansion and, instead, focused on different issues, including this year’s debate over whether hospital rates for safety net providers should be “enhanced.” Because respected Senate leaders, even within the same party, have opposing positions, it’s hard for stakeholders to understand which side to champion. Consumer advocates support critical safety net providers. But can they be supported through enhanced rates? What does that even mean??
Understanding hospital funding, is not for the feint of heart—particularly in Florida. Years of state cuts to the Medicaid program, including cuts to safety net hospitals, led to a confusing and arcane system of hospital funding. Adding to the confusion is that separate funding formulas for different hospitals exist within the state’s managed care system (referred to as “LIP” payments) as opposed to the specific rates that each hospital is assigned for the relatively few patients who are still in “fee-for-service” rather than managed care (referred to as “rate enhancements”).
In a nutshell, the Low Income Pool Program (LIP) provides a mechanism by which supplemental payments—separate and apart from regular managed care reimbursement rates—can be made to providers who treat a large percentage of uninsured patients. The state match for the LIP program comes through local funding sources, known as intergovernmental transfers, or IGTs, rather than general revenue; most LIP funding goes to safety nets and it is a defined amount. By contrast, a hospital’s “rate enhancements” represent a projection based on the rates paid by the State for patients in the fee-for-service system. Thus, under a managed care system, a hospital’s rate enhancement distribution can only be projected since it depends on 2 variables:1) the extent to which managed care company contracts with that individual hospital mirror the hospital’s “enhanced rate” agreed to by the State; and 2) the extent to which a given number of the managed care organization’s enrollees actually receive “enhanced rate” services at that hospital.
As a health care consumer advocate, I’ve spent significant time unpacking and explaining hospital funding so that stakeholders could better understand how the debates over hospital funding fit within the larger health care debate. Notwithstanding these by these efforts, I’m not sure I understand these issues well enough to “take a side” in the current Senate debate. But I do understand enough to note that the current debate isn’t raising the rights questions.
If we can agree that the goal of health care policy should be lowering costs and improving outcomes, two questions should be answered: 1) how can we get more people covered; 2) how can we ensure that coverage dollars are used to improve outcomes? The first question is easy. Unless/until most people are covered, the health care system as a whole (it is ultimately one system), will never be able to effectively control costs and improve outcomes. Because over half a million low income Floridians don’t have access to employer based coverage or coverage in the marketplace, the answer to the first question is simple: accept federal funding to pay for their care under the state’s Medicaid managed care program.
Answering the second question is much harder. But because Florida requires that virtually all Medicaid recipients receive their health care services through a managed care organization (MCO), we can begin. First, MCOs must receive a sufficient amount of funding in order to ensure that medically necessary services are adequately available to their enrollees. Because the federal government will reimburse Florida for roughly 60% of the MCO’s costs (for Medicaid expansion enrollees the federal government would pay 90%), Florida has to come up with a sufficient 40% “state match.” If we do that, theoretically at least, the MCO rates paid to providers will be high enough to ensure adequate provider networks for enrollees —from hospitals to doctors to therapists to midwives. Second, the state Medicaid agency must have sufficient funding to adequately monitor timely access to all medically necessary services.
But back to the safety net hospitals that treat a “disproportionate” number of patients on Medicaid. These patients are, by definition, low–income. It is undisputed that poverty and poor health go hand in hand and that it costs more for providers to treat patients who present in poor health. Additionally, Florida’s safety nets treat a large number of immigrants who are living and working here but who are not eligible for health coverage, even under Medicaid and the ACA. In short, Florida’s safety nets are critical and need to be supported. What is less clear is whether we do that through enhanced hospital rates.
Moreover, improving the health outcomes of low income Floridians means doing a lot more than increasing safety net reimbursement rates. As Maggie Kuhn observed, “the war on poverty has never been more than a skirmish,” and immigration debate in America may be even more contentious than the health care debate. But if Florida can at least address the first question and finally accept federal dollars to cover half a million uninsured Floridians -- we will free up some of the local IGT dollars now used to help safety nets cover the cost of treating the uninsured. Imagine the potential for improved health outcomes if, for example, some of those local tax dollars were freed up for more affordable housing and healthy food gardens?
By Miriam Harmatz, Co-Executive Director of the Florida Health Justice Project
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