2012 LEGISLATIVE AGENDA
New Yorkers for Accessible Health Coverage (NYFAHC) is a statewide coalition of 53 voluntary health organizations and allied groups who serve and represent people with chronic illnesses and disabilities, including cancer, HIV/AIDS, cognitive impairments, multiple sclerosis and epilepsy. Because the conditions affecting the individuals and families we represent do not discriminate between rich and poor, we advocate for accessible, affordable, comprehensive and accountable health insurance for the privately insured, as well as those in need of access to public insurance programs. In implementation of Federal Health Care Reform, we want to protect New York’s private market regulation and comprehensive benefit mandates, as well as it’s public coverage expansions.
ENACT A HEALTH BENEFIT EXCHANGE, IMPLEMENT THE ACA
NYFAHC strongly supports the provisions of the Executive Budget which would establish the New York Health Benefit Exchange. New York must pass legislation to create this exchange as soon as possible so that we will be able to demonstrate our ability to operate the exchange in order to be certified by the federal government on January 13, 2013 or a federally operated exchange will be established in the state by the U.S> Department of Health and human services which is less likely to meet the needs of people with serious illnesses and disabilities. We also need the statutory authority for the exchange in order to apply for over $100 m. in federal funds to build the Exchange. While NYFAHC endorses the Executive Budget Exchange proposal, some improvements could be made.
An Exchange should have a governing board that is free from conflicts of interest, has strong consumer representation and be subject to open meetings law. No one serving on the Exchange Board should receive any financial remuneration from a health insurer, agent or broker, a healthcare provider, health facility, or clinic. This should be made explicit in the language establishing it. There should be strong consumer representation, the meetings should be open to the public, and minutes of the meetings should be made public.
The Exchange should integrate private commercial coverage and public coverage and be capable of enrolling people in the most beneficial program for which they are eligible as required by Exchange guidance. For people with disabilities, who need comprehensive coverage that meets their needs, it will be particularly important that the Exchange be able to do a thorough evaluation of eligibility that takes into consideration disability or diagnosis related Medicaid such as Medicaid Buy-in, Medicaid Spendown, and the Medicaid Cancer Treatment Program. Under current law, the Medicaid agency must not deny or terminate Medicaid based on income without exploring all possible avenues of eligibility. HRA has not been adept at complying with this. We see many people who have an increase in earned income and who are told they are ineligible for Medicaid when, in reality, they have a disability and are eligible for Medicaid Buy-in. In establishing an Exchange, we have an opportunity to correct this problem. We would not want an Exchange to enroll a person with a disability in private commercial coverage with a premium subsidy when that coverage is underinsurance, given the person’s disability, and they are eligible for Medicaid Buy-in. We also wouldn’t want a person to be enrolled in Family Health Plus, which does not cover their Methadone program, when they are eligible for Medicaid with a $46 spendown which provides this coverage. The Exchange must be capable of recognizing the need for coverage that will adequately serve people with disabilities. The website and call center must ask applicants if they might have a disability, a cancer diagnosis, or a pre-cancerous condition being treated. The in-person assistance available through the Exchange must be familiar with disability related and cancer diagnosis related Medicaid eligibility and any navigators or consumer assistance available through the Exchange must be disability competent. The budget contains $2 m. appropriation, which will draw down a full $20 m. for this year, and $3 m., which will draw down $30 m. next year, to support this work.
Merge the individual direct pay and small group health insurance pools. The Exchange legislation proposed by Governor Cuomo in the 2012 budget includes a study of the effect of merging the individual direct pay and small group health insurance pools for risk sharing purposes. NYFAHC strongly urges that this option be adopted. High premiums and shrinking enrollment have created a vicious feedback loop in the individual market with Direct Pay HMO/POS enrollment plummeting from over 100,000 in 2000 to less than 25,000 today, and the market is in a state of collapse. While an individual mandate will bring new purchasers into the market and will lower prices to a degree, both affordability and choice for individuals would be even more enhanced by a market merger. Urban Institute’s modeling of an Exchange with a merged market found that the average single premium would be 70% lower than the average annual single premium in the current direct pay market ($4,540 v. $15,273). With a non-merged group and non-group market, non-group premium would increase by 14%, employer sponsored insurance premiums would only decrease by 1% and 53,000 more people would be uninsured. But the benefits of a merged market go beyond just affordability. In a world in which there is great fluidity between employment by employers, self-employment and unemployment, there is no reason why the same set of insurance options should not be continuously available to all people regardless of the category they may find themselves in at a given time. Loss of a job should not mean having to switch to an entirely different insurance product. In addition, the transition to a single market could be accomplished with the least disruption if done simultaneously with setting up the new Exchange.
To minimize adverse selection, New York should require insurers participating in the Exchange to offer standardized health plans sold in the Exchange to individuals and small groups outside the Exchange.
New York should structure risk adjustment to protect the integrity of policies that provide high actuarial value products to people with serious illness and disability. Currently proposed Exchange legislation also provides for the study of risk adjustment mechanisms. Any risk adjustment mechanism should be carefully structured to ensure that insurers are required to use funds generated through risk adjustment to support and subsidize, not only insurers that suffer disproportionate claims experience, but the particular products sold by those insurers where the high cost individuals tend to enroll.
Current required benefits under the insurance law should be maintained in policies sold inside and outside the Exchange. The Exchange proposal in the budget requires study of whether the state should maintain all its current health mandates and, if so, how it will finance the mandatory provision of any benefits that exceed the essential health benefits defined under the ACA. The individuals with serious or chronic illness or disability whom NYFAHC serves are often dependent on state mandated benefits for effective and truly comprehensive health care. NYFAHC urges the state to ensure that any study of current mandates consult with the populations currently using the benefits in assessing their need; and to adopt and defend a method of assessing the cost of such benefits which takes into account other costs avoided as a result of the improvements in health associated with the mandates. To avoid adverse selection, the same mandated benefits should be required in products both inside and outside the Exchange.
New York should continue to require all benefits currently required under the public health law and social services law to newly Medicaid eligible individuals regardless of whether they are identified as “benchmark benefits” by the Secretary of Health and Human Services.
Some of the newly eligible individuals will have serious illnesses and disabilities that require access to comprehensive benefits and treatments. In fact the Secretary has indicated that some of the previously in “optional groups” that included people with disabilities will in the new “mandatory adult group” that could receive benchmark benefits which would constitute underinsurance, given their medical condition. This could include people in the two year waiting period for Medicare. We should not have similarly situated individuals receiving different Medicaid coverage in New York.
Apply the Managed Care Bill of Rights/Appeals processes to cover all products in the insurance market (EPOs, PPOs). New York’s Managed Care Consumer Bill of Rights contains strong protections for consumers in managed care plans that were further enhanced during last year’s legislative session. The Bill of Rights was enacted in an era in which only managed care plans operated through contracted networks of physicians. Their restrictions on access to care contrasted with indemnity insurers that reimbursed consumers for covered care by any licensed medical provider. In recent years, however, indemnity insurers have adopted the network model as well, and they have as a result created obstacles to access to appropriate specialty care similar to those facing managed care enrollees in the early 1990s. Conforming legislation is required to subject EPO, PPO and similar plans to the same network adequacy requirements as managed care plans and to require them to cover services outside the network when in-network services are not adequate. Further, the Department of Financial Services should ensure that New York's recently enacted provisions extending external review of health plan decisions to disputes over the setting of care are interpreted to give consumers a right to external appeal when they are denied access to out of network specialists or specialists with particular expertise, whether in managed care or other plans.
NYFAHC urges the Legislature to support the State’s implementation of the Community First Choice Option in federal health reform, to which the State has committed. Adoption of CFC will ensure the State draws down an additional 6% FMAP, an estimated $90 m. per year, for services provided under the Option. CFC should serve as the centerpiece in an aggressive Olmstead implementation strategy to ensure the right of individuals with disabilities to be served in the most integrated setting appropriate to their needs. CFC will change lives and save the State Medicaid dollars.
REVISIT LIMITS ON MEDICAID BENEFITS AND SERVICES
Last year’s budget implemented a number of limits on Medicaid benefits and services primarily for the expected cost savings. Since the passage of last year’s budget the Medicaid Redesign Team adopted the recommendations of its Basic Benefit Review Workgroup that included the principle that these sorts of decisions would be based on evidence derived from an assessment of effectiveness, benefits, harms, and costs.
20 visit limit on Physical Therapy, Occupational Therapy, and Speech Therapy should be subject to an override. Arbitrary hard caps like these may not make sense in all situations. People who have a stroke may need more than 20 physical therapy visits to regain the function of walking. People subject to these limits may require surgery as a result or experience depression that may require therapy or prescription drug treatment. Medicaid Utilization Thresholds which have been used in New York have provided a procedure for a physician override. Such a procedure should be implemented with these limits.
Enteral Formula should be permitted for people have who wasting and should be subject to an override. Last year’s budget limited enteral formula (like Ensure) to people who have tube feeding or people with inborn metabolic disorders. This year’s budget expands it to people with HIV-related wasting. Coverage should be expanded to people who have wasting related to any diagnosis and should be subject to an override.
Limits on orthopedic shoes, orthotics, and compression stocking should be subject to an override. Last year’s budget limited orthopedic shoes and orthotics to children with growth and development problems, diabetics, and situations in which a shoe was attached to a lower limb orthotic or brace. Compression stockings are covered only for treatment of open wounds and during pregnancy. We have encountered a consumer who did not have the exact permitted conditions who was at risk of falling and was likely to need surgery if custom made shoes were denied. A procedure for a physician override should be implemented for these limits as well.
RESPONSE TO EXECUTIVE BUDGET PROPOSAL
Support streamlined and increased funding for Consumer Assistance
Because of the rapid and enormous changes in the way that people with serious illnesses and disabilities will be getting their care, it is important that additional resources be dedicated to ensuring that people with serious illnesses and disabilities get the services and supports that are right for them. This year’s proposed Executive Budget contains language authorizing contracts with one of more entities to engage in education, outreach services, and facilitated enrollment activities for aged, blind, and disabled persons who may be eligible for Medicaid and appropriates $1.5 m. in state funds for such assistance. It also contains a dry appropriation for Community Health Advocates (CHA) New York’s Statewide Consumer Assistance Program established under the Affordable Care Act which provides individual counseling and education to New Yorkers who need it about all types of coverage. Last year CHA helped 28,589 New Yorkers who needed help finding or using their health insurance. NYFAHC supports a funded initiative to ensure more education, outreach and enrollment assistance for people with disabilities and older New Yorkers in need of long term services. We also support appropriations for Community Health Advocates. Ideally this consumer assistance and assistance provided through the Exchange would arranged in such a way that it would be integrated so that there would be no wrong door for someone seeking assistance.
Support increased funding for Office of Administrative Hearings. The state hopes to embark on a fairly radical transition to mandatory enrollment in managed long term care and other care coordination models. Concerns about capitation arrangements that offer incentives to reduce services and different assessments of need for those services make it necessary that the Office of Fair Hearings have adequate resources and training so that consumers have full access to the existing fair hearing process to protect their full due process rights and ensure adequate care. The Executive Budget appropriates $.5 m. for this purpose. NYFAHC supports this as a good first step.
Reject the Elimination of Spousal/Parental refusal. This proposal will harm low income couple’s where the spouse in need of care will be forced into an institution or divorce in order to prevent impoverishment. Rather than eliminate the spousal refusal provision outright, NYFAHC would like to see this provision modified to limits its availability to only those spouses or parents whose income and assets fall within the spousal impoverishment limits for nursing home care ($2841 in monthly income and at least $74,820 and up to $109,560 in resources). While this income is protected for a community spouse of a person entering a nursing home, the same spouse who seeks to obtain Medicaid home care to care for his wife at home, must impoverish himself so that the couple’s combined assets are &20850 and combined income is $1179 a month. This creates a huge pressure on the “well Spouse” to institutionalize the disabled spouse. The only alternative is divorce. A hardship exception should continue to apply to cases in which the spouse truly refuses to contribute or document his or her assets to protect inform spouses in domestic violence or abuse and neglect situations where, though a couple may live together, only one controls the money or finances.
Support the requirement that managed care plans and managed long term care plans offer the consumer directed personal assistance care program to their enrollees. All consumers should have the option to independently recruit, hire, train, and supervise their own personal assistants. As this requirement is implemented, we expect that the existing Consumer Directed Personal Assistance Program (CDPAP) model, affirmed by the regulations 18 NYCRR 505.28, be preserved and that the Fiscal Intermediaries (FI) remain separate and distinct from assessment and authorizing functions.
Improve New York’s Hospital Financial Assistance Program. Each year, New York’s hospitals receive over $ 1 billion in funding from New York’s Indigent Care pool to help pay for the cost of providing care for uninsured and underinsured New Yorkers. As a requirement for these payments, hospitals must comply with the Hospital Financial Assistance Law. The Budget proposes an adjustment to the distribution formula for part of Medicaid’s Disproportionate Share Hospital (DSH) funding, funding intended to compensate hospitals that provide high volumes of Medicaid and uncompensated care and care. The adjustment would eliminate bad debt from the formula used for funds distributed through the Office of Mental Health, but it does not go far enough. As recommended by the Governor’s Medicaid Redesign Team, NYFAHC urges the state to enforce HFAL compliance to ensure that all patients who qualify for financial assistance receive it and take the necessary steps to make the Indigent Care Pool payments 100% accountable.
REDUCE HEALTH DISPARITIES
People experience different access to care and different health outcomes based on their race and ethnicity, gender identity, disability and housing status. The Medicaid Redesign Team’s Health Disparities Workgroup made 14 recommendations to address these health disparities which were adopted by the Medicaid Redesign Team.
Data collection to Measure Health Disparities. The Executive Budget implements and expands on the data collection standards required the Affordable Care Act by including detailed reporting on race and ethnicity, gender identity, the six disability questions used in the American Community Survey, and housing status. In addition it provides funding to support data analyses and research to promote programs and policies that will better identify, understand, and address disparities. $1 m in state fund and $2m in all funds is included for this. We urge the legislature to support this provision in the budget and to require uniform collection and reporting of data stratified by race, ethnicity, disability status, gender, and language spoken throughout the state by all public and private health plans, hospitals and other health care institutions.
Improve Language Access to Address Disparities. The Executive Budget amends Medicaid rates for hospitals, diagnostic and treatment centers, and health centers to provide reimbursement for the costs of interpretation services for patients with limited English proficiency and communication services for people who are deaf or hard of hearing and provides $1.35 m. in state funds for it. NYFAHC supports this proposal and recommends a statewide policy that requires all state agencies to provide language assistance services, including necessary interpreter services and communication services and the translation of frequently used forms and documents.
Promote Language Accessible Prescriptions. In 2009, the NY Attorney General announced a landmark settlement with New York’s largest pharmacy chains requiring them to provide free translation of medicine labels. The Executive budget contains language that would require a prescriber to indicate the primary language of someone who is limited English proficient on the prescription form and require pharmacists to provide for translation or other language services if they have reason to know that the person is limited English proficient. NYFAHC supports this proposal. Standardized and translated prescription labels should be required to ensure understanding and comprehension.
Permit Pre-qualification for Emergency Medicaid. Emergency Medicaid is available to allow income New Yorkers, regardless of immigration status. To get coverage, an attending physician must certify that the person has a medical condition that meets the definition of an “emergency.” If so, the person fills out a full Medicaid application which, depending on their eligibility, may or may not be approved. The Governor’s MRT recently recommended that New Yorkers be allowed to pre-qualify for Emergency Medicaid in advance of any need for medical care. This would raise the awareness of Emergency Medicaid and give providers assurance of payment for services provided. Many states already do this: California, Michigan, Oregon, Massachusetts, South Carolina, Texas, Maine, Nevada, Arizona, Virginia, Maryland, Louisiana, Delaware and New Hampshire. NYFAHC asks the State to pass legislation to support this important safety-net measure.
New Yorkers for Accessible Health Coverage (NYFAHC) is a statewide coalition of 53 voluntary health organizations and allied groups who serve and represent people with chronic illnesses and disabilities, including cancer, HIV/AIDS, cognitive impairments, multiple sclerosis and epilepsy. Because the conditions affecting the individuals and families we represent do not discriminate between rich and poor, we advocate for accessible, affordable, comprehensive and accountable health insurance for the privately insured, as well as those in need of access to public insurance programs. In implementation of Federal Health Care Reform, we want to protect New York’s private market regulation and comprehensive benefit mandates, as well as it’s public coverage expansions.
ENACT A HEALTH BENEFIT EXCHANGE, IMPLEMENT THE ACA
NYFAHC strongly supports the provisions of the Executive Budget which would establish the New York Health Benefit Exchange. New York must pass legislation to create this exchange as soon as possible so that we will be able to demonstrate our ability to operate the exchange in order to be certified by the federal government on January 13, 2013 or a federally operated exchange will be established in the state by the U.S> Department of Health and human services which is less likely to meet the needs of people with serious illnesses and disabilities. We also need the statutory authority for the exchange in order to apply for over $100 m. in federal funds to build the Exchange. While NYFAHC endorses the Executive Budget Exchange proposal, some improvements could be made.
An Exchange should have a governing board that is free from conflicts of interest, has strong consumer representation and be subject to open meetings law. No one serving on the Exchange Board should receive any financial remuneration from a health insurer, agent or broker, a healthcare provider, health facility, or clinic. This should be made explicit in the language establishing it. There should be strong consumer representation, the meetings should be open to the public, and minutes of the meetings should be made public.
The Exchange should integrate private commercial coverage and public coverage and be capable of enrolling people in the most beneficial program for which they are eligible as required by Exchange guidance. For people with disabilities, who need comprehensive coverage that meets their needs, it will be particularly important that the Exchange be able to do a thorough evaluation of eligibility that takes into consideration disability or diagnosis related Medicaid such as Medicaid Buy-in, Medicaid Spendown, and the Medicaid Cancer Treatment Program. Under current law, the Medicaid agency must not deny or terminate Medicaid based on income without exploring all possible avenues of eligibility. HRA has not been adept at complying with this. We see many people who have an increase in earned income and who are told they are ineligible for Medicaid when, in reality, they have a disability and are eligible for Medicaid Buy-in. In establishing an Exchange, we have an opportunity to correct this problem. We would not want an Exchange to enroll a person with a disability in private commercial coverage with a premium subsidy when that coverage is underinsurance, given the person’s disability, and they are eligible for Medicaid Buy-in. We also wouldn’t want a person to be enrolled in Family Health Plus, which does not cover their Methadone program, when they are eligible for Medicaid with a $46 spendown which provides this coverage. The Exchange must be capable of recognizing the need for coverage that will adequately serve people with disabilities. The website and call center must ask applicants if they might have a disability, a cancer diagnosis, or a pre-cancerous condition being treated. The in-person assistance available through the Exchange must be familiar with disability related and cancer diagnosis related Medicaid eligibility and any navigators or consumer assistance available through the Exchange must be disability competent. The budget contains $2 m. appropriation, which will draw down a full $20 m. for this year, and $3 m., which will draw down $30 m. next year, to support this work.
Merge the individual direct pay and small group health insurance pools. The Exchange legislation proposed by Governor Cuomo in the 2012 budget includes a study of the effect of merging the individual direct pay and small group health insurance pools for risk sharing purposes. NYFAHC strongly urges that this option be adopted. High premiums and shrinking enrollment have created a vicious feedback loop in the individual market with Direct Pay HMO/POS enrollment plummeting from over 100,000 in 2000 to less than 25,000 today, and the market is in a state of collapse. While an individual mandate will bring new purchasers into the market and will lower prices to a degree, both affordability and choice for individuals would be even more enhanced by a market merger. Urban Institute’s modeling of an Exchange with a merged market found that the average single premium would be 70% lower than the average annual single premium in the current direct pay market ($4,540 v. $15,273). With a non-merged group and non-group market, non-group premium would increase by 14%, employer sponsored insurance premiums would only decrease by 1% and 53,000 more people would be uninsured. But the benefits of a merged market go beyond just affordability. In a world in which there is great fluidity between employment by employers, self-employment and unemployment, there is no reason why the same set of insurance options should not be continuously available to all people regardless of the category they may find themselves in at a given time. Loss of a job should not mean having to switch to an entirely different insurance product. In addition, the transition to a single market could be accomplished with the least disruption if done simultaneously with setting up the new Exchange.
To minimize adverse selection, New York should require insurers participating in the Exchange to offer standardized health plans sold in the Exchange to individuals and small groups outside the Exchange.
New York should structure risk adjustment to protect the integrity of policies that provide high actuarial value products to people with serious illness and disability. Currently proposed Exchange legislation also provides for the study of risk adjustment mechanisms. Any risk adjustment mechanism should be carefully structured to ensure that insurers are required to use funds generated through risk adjustment to support and subsidize, not only insurers that suffer disproportionate claims experience, but the particular products sold by those insurers where the high cost individuals tend to enroll.
Current required benefits under the insurance law should be maintained in policies sold inside and outside the Exchange. The Exchange proposal in the budget requires study of whether the state should maintain all its current health mandates and, if so, how it will finance the mandatory provision of any benefits that exceed the essential health benefits defined under the ACA. The individuals with serious or chronic illness or disability whom NYFAHC serves are often dependent on state mandated benefits for effective and truly comprehensive health care. NYFAHC urges the state to ensure that any study of current mandates consult with the populations currently using the benefits in assessing their need; and to adopt and defend a method of assessing the cost of such benefits which takes into account other costs avoided as a result of the improvements in health associated with the mandates. To avoid adverse selection, the same mandated benefits should be required in products both inside and outside the Exchange.
New York should continue to require all benefits currently required under the public health law and social services law to newly Medicaid eligible individuals regardless of whether they are identified as “benchmark benefits” by the Secretary of Health and Human Services.
Some of the newly eligible individuals will have serious illnesses and disabilities that require access to comprehensive benefits and treatments. In fact the Secretary has indicated that some of the previously in “optional groups” that included people with disabilities will in the new “mandatory adult group” that could receive benchmark benefits which would constitute underinsurance, given their medical condition. This could include people in the two year waiting period for Medicare. We should not have similarly situated individuals receiving different Medicaid coverage in New York.
Apply the Managed Care Bill of Rights/Appeals processes to cover all products in the insurance market (EPOs, PPOs). New York’s Managed Care Consumer Bill of Rights contains strong protections for consumers in managed care plans that were further enhanced during last year’s legislative session. The Bill of Rights was enacted in an era in which only managed care plans operated through contracted networks of physicians. Their restrictions on access to care contrasted with indemnity insurers that reimbursed consumers for covered care by any licensed medical provider. In recent years, however, indemnity insurers have adopted the network model as well, and they have as a result created obstacles to access to appropriate specialty care similar to those facing managed care enrollees in the early 1990s. Conforming legislation is required to subject EPO, PPO and similar plans to the same network adequacy requirements as managed care plans and to require them to cover services outside the network when in-network services are not adequate. Further, the Department of Financial Services should ensure that New York's recently enacted provisions extending external review of health plan decisions to disputes over the setting of care are interpreted to give consumers a right to external appeal when they are denied access to out of network specialists or specialists with particular expertise, whether in managed care or other plans.
NYFAHC urges the Legislature to support the State’s implementation of the Community First Choice Option in federal health reform, to which the State has committed. Adoption of CFC will ensure the State draws down an additional 6% FMAP, an estimated $90 m. per year, for services provided under the Option. CFC should serve as the centerpiece in an aggressive Olmstead implementation strategy to ensure the right of individuals with disabilities to be served in the most integrated setting appropriate to their needs. CFC will change lives and save the State Medicaid dollars.
REVISIT LIMITS ON MEDICAID BENEFITS AND SERVICES
Last year’s budget implemented a number of limits on Medicaid benefits and services primarily for the expected cost savings. Since the passage of last year’s budget the Medicaid Redesign Team adopted the recommendations of its Basic Benefit Review Workgroup that included the principle that these sorts of decisions would be based on evidence derived from an assessment of effectiveness, benefits, harms, and costs.
20 visit limit on Physical Therapy, Occupational Therapy, and Speech Therapy should be subject to an override. Arbitrary hard caps like these may not make sense in all situations. People who have a stroke may need more than 20 physical therapy visits to regain the function of walking. People subject to these limits may require surgery as a result or experience depression that may require therapy or prescription drug treatment. Medicaid Utilization Thresholds which have been used in New York have provided a procedure for a physician override. Such a procedure should be implemented with these limits.
Enteral Formula should be permitted for people have who wasting and should be subject to an override. Last year’s budget limited enteral formula (like Ensure) to people who have tube feeding or people with inborn metabolic disorders. This year’s budget expands it to people with HIV-related wasting. Coverage should be expanded to people who have wasting related to any diagnosis and should be subject to an override.
Limits on orthopedic shoes, orthotics, and compression stocking should be subject to an override. Last year’s budget limited orthopedic shoes and orthotics to children with growth and development problems, diabetics, and situations in which a shoe was attached to a lower limb orthotic or brace. Compression stockings are covered only for treatment of open wounds and during pregnancy. We have encountered a consumer who did not have the exact permitted conditions who was at risk of falling and was likely to need surgery if custom made shoes were denied. A procedure for a physician override should be implemented for these limits as well.
RESPONSE TO EXECUTIVE BUDGET PROPOSAL
Support streamlined and increased funding for Consumer Assistance
Because of the rapid and enormous changes in the way that people with serious illnesses and disabilities will be getting their care, it is important that additional resources be dedicated to ensuring that people with serious illnesses and disabilities get the services and supports that are right for them. This year’s proposed Executive Budget contains language authorizing contracts with one of more entities to engage in education, outreach services, and facilitated enrollment activities for aged, blind, and disabled persons who may be eligible for Medicaid and appropriates $1.5 m. in state funds for such assistance. It also contains a dry appropriation for Community Health Advocates (CHA) New York’s Statewide Consumer Assistance Program established under the Affordable Care Act which provides individual counseling and education to New Yorkers who need it about all types of coverage. Last year CHA helped 28,589 New Yorkers who needed help finding or using their health insurance. NYFAHC supports a funded initiative to ensure more education, outreach and enrollment assistance for people with disabilities and older New Yorkers in need of long term services. We also support appropriations for Community Health Advocates. Ideally this consumer assistance and assistance provided through the Exchange would arranged in such a way that it would be integrated so that there would be no wrong door for someone seeking assistance.
Support increased funding for Office of Administrative Hearings. The state hopes to embark on a fairly radical transition to mandatory enrollment in managed long term care and other care coordination models. Concerns about capitation arrangements that offer incentives to reduce services and different assessments of need for those services make it necessary that the Office of Fair Hearings have adequate resources and training so that consumers have full access to the existing fair hearing process to protect their full due process rights and ensure adequate care. The Executive Budget appropriates $.5 m. for this purpose. NYFAHC supports this as a good first step.
Reject the Elimination of Spousal/Parental refusal. This proposal will harm low income couple’s where the spouse in need of care will be forced into an institution or divorce in order to prevent impoverishment. Rather than eliminate the spousal refusal provision outright, NYFAHC would like to see this provision modified to limits its availability to only those spouses or parents whose income and assets fall within the spousal impoverishment limits for nursing home care ($2841 in monthly income and at least $74,820 and up to $109,560 in resources). While this income is protected for a community spouse of a person entering a nursing home, the same spouse who seeks to obtain Medicaid home care to care for his wife at home, must impoverish himself so that the couple’s combined assets are &20850 and combined income is $1179 a month. This creates a huge pressure on the “well Spouse” to institutionalize the disabled spouse. The only alternative is divorce. A hardship exception should continue to apply to cases in which the spouse truly refuses to contribute or document his or her assets to protect inform spouses in domestic violence or abuse and neglect situations where, though a couple may live together, only one controls the money or finances.
Support the requirement that managed care plans and managed long term care plans offer the consumer directed personal assistance care program to their enrollees. All consumers should have the option to independently recruit, hire, train, and supervise their own personal assistants. As this requirement is implemented, we expect that the existing Consumer Directed Personal Assistance Program (CDPAP) model, affirmed by the regulations 18 NYCRR 505.28, be preserved and that the Fiscal Intermediaries (FI) remain separate and distinct from assessment and authorizing functions.
Improve New York’s Hospital Financial Assistance Program. Each year, New York’s hospitals receive over $ 1 billion in funding from New York’s Indigent Care pool to help pay for the cost of providing care for uninsured and underinsured New Yorkers. As a requirement for these payments, hospitals must comply with the Hospital Financial Assistance Law. The Budget proposes an adjustment to the distribution formula for part of Medicaid’s Disproportionate Share Hospital (DSH) funding, funding intended to compensate hospitals that provide high volumes of Medicaid and uncompensated care and care. The adjustment would eliminate bad debt from the formula used for funds distributed through the Office of Mental Health, but it does not go far enough. As recommended by the Governor’s Medicaid Redesign Team, NYFAHC urges the state to enforce HFAL compliance to ensure that all patients who qualify for financial assistance receive it and take the necessary steps to make the Indigent Care Pool payments 100% accountable.
REDUCE HEALTH DISPARITIES
People experience different access to care and different health outcomes based on their race and ethnicity, gender identity, disability and housing status. The Medicaid Redesign Team’s Health Disparities Workgroup made 14 recommendations to address these health disparities which were adopted by the Medicaid Redesign Team.
Data collection to Measure Health Disparities. The Executive Budget implements and expands on the data collection standards required the Affordable Care Act by including detailed reporting on race and ethnicity, gender identity, the six disability questions used in the American Community Survey, and housing status. In addition it provides funding to support data analyses and research to promote programs and policies that will better identify, understand, and address disparities. $1 m in state fund and $2m in all funds is included for this. We urge the legislature to support this provision in the budget and to require uniform collection and reporting of data stratified by race, ethnicity, disability status, gender, and language spoken throughout the state by all public and private health plans, hospitals and other health care institutions.
Improve Language Access to Address Disparities. The Executive Budget amends Medicaid rates for hospitals, diagnostic and treatment centers, and health centers to provide reimbursement for the costs of interpretation services for patients with limited English proficiency and communication services for people who are deaf or hard of hearing and provides $1.35 m. in state funds for it. NYFAHC supports this proposal and recommends a statewide policy that requires all state agencies to provide language assistance services, including necessary interpreter services and communication services and the translation of frequently used forms and documents.
Promote Language Accessible Prescriptions. In 2009, the NY Attorney General announced a landmark settlement with New York’s largest pharmacy chains requiring them to provide free translation of medicine labels. The Executive budget contains language that would require a prescriber to indicate the primary language of someone who is limited English proficient on the prescription form and require pharmacists to provide for translation or other language services if they have reason to know that the person is limited English proficient. NYFAHC supports this proposal. Standardized and translated prescription labels should be required to ensure understanding and comprehension.
Permit Pre-qualification for Emergency Medicaid. Emergency Medicaid is available to allow income New Yorkers, regardless of immigration status. To get coverage, an attending physician must certify that the person has a medical condition that meets the definition of an “emergency.” If so, the person fills out a full Medicaid application which, depending on their eligibility, may or may not be approved. The Governor’s MRT recently recommended that New Yorkers be allowed to pre-qualify for Emergency Medicaid in advance of any need for medical care. This would raise the awareness of Emergency Medicaid and give providers assurance of payment for services provided. Many states already do this: California, Michigan, Oregon, Massachusetts, South Carolina, Texas, Maine, Nevada, Arizona, Virginia, Maryland, Louisiana, Delaware and New Hampshire. NYFAHC asks the State to pass legislation to support this important safety-net measure.
