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Update on the Appellate Court's ruling

You may have heard about a recent ruling over TJC’s lawsuit to improve TennCare services for children. The story has been featured in the Tennessean and in other local media. In case you hadn’t heard, the State had appealed to the 6th Circuit Court of Appeals, asking them to set aside the Consent Decree that TJC negotiated to ensure that TennCare complies with federal law and provides low-income and medically fragile children with the health care they need. A consent decree is an agreement made by both sides of the case to take steps that the court will oversee. The State also asked that the case be reassigned to a new lower court judge for future proceedings.

TJC argued against both setting aside the Consent Decree and reassigning the case. Ultimately, the court did rule that a new judge should be assigned to the case. In 2006, the federal court had asked the State what its plan was for complying with the law that promises children the health care they need. The State said there was no need for a plan because it was already in compliance. Since then, TJC has been monitoring the State’s compliance to its obligations to Tennessee’s children under the Consent Decree. The monitoring and discovery process has been very contentious, delaying a trial on the merits of the case. The Appeals Court noted the “strategy of contention” that the State has pursued has dragged the case out, but it ultimately ruled to reassign the case to a new judge.

The Appeals Court did not, however, relieve the State from its obligations under the Consent Decree. It refused to lift the State’s obligation to provide services to low-income and medically-fragile children in Tennessee. TJC remains committed to holding the State accountable to its most vulnerable citizens. Though the immediate future of this case remains unclear, what is certain is that TJC will continue to stand with Tennessee children when their HMOs deny them the services their doctors say they need.

We are hoping that these new developments will give the State a chance to reconsider its tactics and shift its focus to fulfilling its obligations to children. Legal wars of attrition are not in the interest of taxpayers who have to pay out-of-state lawyers’ huge legal fees. More importantly, focusing on these fights instead of children’s health is costly to the state for generations to come. Our case has never been about TJC’s lawyers scoring points in the courtroom – it is about ensuring that TennCare enrollees get the services they are promised by the law. These are services that taxpayers have already paid HMOs to provide, but the State must hold its contactors more accountable. As long as the State and its HMOs continue to deny children medically necessary services, we will continue to challenge the State’s failures and work to make things right.

Health Care Story - 11/10/10

Mary and Joe’s foster son, Timmy, is severely autistic and intellectually disabled. Timmy is almost completely nonverbal and can use very limited sign language. Nevertheless, he loves music, watching Barney, and playing on the swing in his yard. Timmy also has dysphasia, esophageal problems, and reflux problems that require regular suctioning. Timmy’s doctor prescribed speech therapy to help him communicate better, but many speech therapists would not treat Timmy because he was too difficult.
      
Then Timmy’s parents found Susan Hock, a speech therapist at the Parent-Child Services Group in Knoxville, TN. Therapist Hock stuck with Timmy, and he started showing signs of improvement – sitting still, paying attention, correctly using some sign language, and playing simple computer games. And Timmy likes working with Susan. Now that she has worked with Timmy for several years, they have an established relationship, which is vital for Timmy because he has trouble meeting and working with new people. Due to Susan’s hard work with Timmy, he was able to have his feeding tube removed, reducing his risk of feeding-tube related infections.
     
Despite all of Timmy’s progress, TennCare said that Timmy would have to switch to a new therapist. TJC worked with the family to keep getting Timmy the care he needed. After TJC filed an appeal and sent TennCare letters of support from Timmy’s medical providers, TennCare decided the appeal in favor of Timmy and his parents – he could keep getting therapy from therapist Hock.
      
Mary said afterward, “I was very pleased with the results of the appeal…I also appreciate the concern and care that Susanne showed us.”
      
The Tennessee Justice Center works to help children get the care they need. We accept calls from providers as well as parents. If you know a child who is waiting for care, call us.

Health Care Story - 9/8/2010

Shondrea is a vibrant, determined 28-year-old woman who wants to make her mark on the world. While she was a full-time college student, Shondrea worked as a hotel night auditor while balancing a full load of classes in social work. She knows what it means to work hard, and she wants to have a career that will help to improve the lives of others.

At the moment, however, Shondrea is fighting for her own life. Almost eight years ago, at age 21, she was diagnosed with lupus, a chronic, autoimmune disorder that causes inflammation in the body’s organs. Although she was able to control her symptoms for several years through expensive treatments and medications while on private insurance, her situation changed significantly under the stress of college combined with long, late-night shifts at the hotel. Her body exhausted, Shondrea’s organs began to break down.

Beginning in late 2008, Shondrea began having difficulties breathing, and fluid started accumulating around her heart. After going to the hospital more than once to have the fluid drained, she underwent surgery to implant a device around her heart to reduce the accumulation of fluid. Since her surgery, she has been regularly seeing several specialists who monitor her condition and are treating her with lifesaving medications. Lupus has also attacked Shondrea’s lungs and kidneys, and the weakening of her lungs makes her unable to walk or exercise.

Due to her current medical condition, Shondrea cannot return to school or work. She was deemed disabled in 2009 and lives on just over $1,000 per month in SSDI. Because Shondrea no longer receives SSI payments, she is losing her TennCare. She has a hearing next month, but the state’s rules make it very hard for a childless adult, like Shondrea, to be on TennCare.

If Shondrea loses TennCare, she has few health insurance options. Shondrea must wait two years from when she was determined disabled – until mid-2011 – to qualify for Medicare. This two year gap leaves people with severe disabilities out in the cold when they need health insurance most. In the meanwhile, Shondrea requires regular visits to her specialists and medications. If she stops treatment, her doctor has given her a life expectancy of fewer than ten years.

Private health insurance will not cover Shondrea because she is uninsurable. Her only other option is a high risk pool – either AccessTN, the state’s health insurance for residents who are uninsurable due to pre-existing medical conditions, or a new federal high risk pool. AccessTN is less expensive, and yet Shondrea would still have to pay a monthly premium plus a deductible, a financial stretch on her fixed income.

Not only is Shondrea in the middle of a two year gap, waiting for Medicare coverage to kick in, she’s one of millions of low-income adults who are waiting for 2014, when they will qualify for Medicaid. One provision of the Affordable Care Act mandates that all persons – including those, like Shondrea, without children – who earn less than 133% of the Federal Poverty Level are eligible for their state’s Medicaid program, such as TennCare. If that law were already in effect, Shondrea would not be facing the possibility of being disenrolled from TennCare. For Shondrea, and many others like her, health care reform cannot come soon enough.

TJC Commentary - TJC's Jennifer Tlumak Shares Her Thoughts on Healthcare Changes

Our nation’s health insurance and delivery system is changing, and TJC is keeping pace, ensuring our clients have access to current information on locating, obtaining, and keeping meaningful health care coverage for their families. The Affordable Care Act, or “health reform” as it’s popularly known, is the law of the land. The law has lots of benefits for our clients, and although key provisions have yet to go into effect, we’re already seeing the real world impact of this historic legislation.

A breast cancer survivor who’s losing TennCare may be able to get immediate coverage, without being screened for pre-existing conditions, in the federal high risk pool that began on July 1, 2010. An elderly uninsured woman with extensive prescription drug needs may also benefit. This new high risk pool created by Affordable Care Act has some benefits over the state version, AccessTN. For example, the federal program has no waiting period for coverage of major medical conditions, and that’s a huge benefit to some of our clients.

A small child with seizures who relies on his father’s employee insurance plan will not be subject to pre-existing exclusions starting in early 2011, when their plan year begins. Health reform is the reason this child and his family will be protected from high out-of-pocket medical costs for his rare disease. The child will be covered, and the private insurance company will be responsible for covering this sick child – including his pre-existing condition – as well as his healthy siblings.

We still don’t have a perfect solution to our nation’s health care problems. But the changes are encouraging: ending rescissions and discrimination on the basis of pre-existing conditions, extending coverage to very low-income adults, providing subsidies so that more people can afford better insurance, and regulating the insurance companies by mandating that they put patient care ahead of profits. In my daily work with clients, I’m beginning to see the positive impact of some of these changes. I look forward to seeing more benefits as the Affordable Care Act is implemented more fully.

Health Care Story - 7/22/10

Diane adopted Jimmy as a special needs infant when he was only six weeks old. Diane knew that he was born with a cleft palate and some other minor birth defects, but since she has private insurance and (as a special needs adoption) Jimmy also has TennCare, Diane thought all Jimmy’s needs would be covered by insurance.

It turned out that Jimmy’s minor problems at birth became significant impairments as he grew. By age 8, he had been diagnosed with autism, mental retardation, and cerebral palsy. His autism has proven difficult to manage, with behaviors ranging from running into the street and grabbing women’s breasts in public to obsessively chewing warts on his hands and a fascination with the sight of his own blood. Nevertheless, Diane knew that Jimmy had great potential and that all he needed to reach it were the right therapies and treatments. As she told TJC, “Despite his challenges, he is a sweet kid who tries very hard and who inspires most who meet him.”

Diane began searching for therapy to manage Jimmy’s autism soon after he was diagnosed. She even took him to a specialist out of state and paid out of pocket for ABA therapy when her insurance policy said it would not cover the treatment. As he got older and his behaviors worsened, Diane hired specially trained caregivers, once again paying out of pocket, to help care for Jimmy. Over the years, she has spent more than $100,000 of her own money to try to keep Jimmy safe. Unfortunately, all this money and effort has not allowed Jimmy to reach his full potential.

Diane contacted TJC for help getting Jimmy therapy to reduce his harmful behaviors. Jimmy’s PCP and psychiatrist prescribed applied behavioral therapy (ABA), but TennCare denied it as not medically necessary and Diane’s private insurance would not cover the expensive treatment. TJC helped Diane navigate the appeals process and discovered a TennCare procedural error, which allowed Jimmy to receive intensive in home ABA therapy for more than one year. His obsessive biting and other dangerous behaviors have been drastically reduced. In preparation for the family’s TennCare hearing, TJC located a pro bono attorney to assist Diane in court. Based on Jimmy’s severe needs and the successes the ABA treatment had produced, the Judge ordered TennCare to continue providing intensive ABA.

Because he has gotten the health care he needs, Jimmy is adjusting better in school and other public settings. His problem behaviors have gone down. His overall physical and mental health have improved, and he is a happier child. Through the tireless advocacy of dedicated mothers like Diane, Tennessee’s children have a brighter future ahead.

Health Reform Update: New regulations in place to protect consumers

Yesterday, the U.S. Department of Health and Human Services issued regulations that create a new Patients' Bill of Rights under the Affordable Care Act. These regulations, which apply to nearly all health insurance plans, will help children (and eventually all Americans) with pre-existing conditions gain coverage and keep it, protect all Americans’ choice of doctors and end lifetime limits on the care consumers may receive.

How will the rules help you? They will:

• Stop insurance companies from limiting the care you need. These rules stop insurance companies from imposing pre-existing condition exclusions on your children; prohibit insurers from taking away your coverage based on an unintentional mistake on an application; ban insurers from setting lifetime dollar limits on your coverage; and restrict their use of annual limits on coverage.
• Remove insurance company barriers between you and your doctor. These rules ensure that you can choose the primary care doctor or pediatrician you want from your plan’s provider network, and that you can see an OB-GYN without needing a referral. Insurance companies will not be able to require you to get prior approval before seeking emergency care at a hospital outside your plan’s network.

There are also several other new provisions. More info on all of these new changes can be found at http://healthreform.gov/newsroom/new_patients_bill_of_rights.html.