Medicaid Reform Beneficiaries Describe Glitches at Roundtable

August 1, 2007

Diverse Consumers and Providers Share Gaps, Lapses

On July 25, Florida CHAIN, part of the Medicaid Reform Advocates Coalition (MRAC) conducted the 4th in its series of Medicaid Reform Consumer Roundtables. Recognizing that, a year into the pilot program, issues arising concern not only beneficiaries but Community-Based Organizations that provide services to different constituencies, the roundtable also included a number of such providers. Throughout the evening, participants answered a series of questions ranging from changes in delivery and accessibility of services, to being billed for services, to the Enhanced Benefit component of Reform.

Some of the more disturbing consequences of changes brought about by Medicaid reform have been experienced by individuals who rely on mental health services and the delicate balance of therapy and medication that allows them to function.

Sharon Grad described how her daughter Lori, who suffers from severe mental illness, was bounced from one institution to another as her condition worsened, because the plan she was enrolled in would not pay for services she had previously received. “The police took my daughter to Tamarac Pavilion, where she had gone before and was covered by Medicaid. After one day they discharged her because the Reform plan she is in does not cover her there. She was sent by ambulance to a psychiatric hospital where they kept her for a week and discharged her with medication that caused her to pass out. So we called her primary care physician, who had no availability at that time and suggested we take her to Coral Springs Hospital. Unfortunately, what my daughter needed at the time was a psychiatrist to evaluate her medications. But no psychiatrist under her plan could see her at Coral Springs Hospital, so she was kept under observation for three days, and eventually they sent a psychologist. Talking is not what she needed,” she said.

Another participant, Betty Antoine, who is her mother’s caregiver, described how, after getting a list of doctors her mother could see from a Choice Counselor, she found that none of the providers were taking Medicaid patients in the plan she had chosen, “Except for one that was on vacation, so my mother could not see him for two weeks.”

In discussing access to providers, some participants also addressed the issue of transportation, which, under the terms of Reform, must be provided by the Managed Care Companies at the same level or better than by Medicaid.

For Howard Kaplan, who relies on public transportation, getting the needed bus pass was previously provided by Medicaid “like clockwork, on the 19th of every month.” Now that he is enrolled in a Reform plan, it’s become a monthly nightmare. “First the health insurance company told me to contact the transportation subcontractor who is located in Brevard. They sent me forms that I have to fill out every month and told me to fax them back to them, but both of the fax numbers they gave me are down.” In addition, Kaplan now has to have lab work done at facilities that are much further away than before Reform, and require bus transfers.

For Lori Lotter, who is homeless and relies on very limited income, Medicaid Reform has meant that now she has to co-pay $2 each way to and from her medical appointments using transportation company her HMO provides, which in her situation makes a big difference.

On the question of Enhanced Benefits, the program that allows Medicaid beneficiaries to accrue credits for positive health behaviors that they can cash in for over the counter pharmacy products, the response from participants covered the gamut: some had not heard nor received information about it, some who did and tried to cash their benefits at local pharmacies found that the latter had no idea about the program or what products are covered, and two participants had no trouble cashing in their credits.

Kaplan raised an issue that is common to many Medicaid recipients: not being able to rely on the internet to facilitate navigating through the Reform system. “I went to my local Walgreen’s with my enhanced benefit statement and the tech there told me to contact AHCA to find out what products are available,” said Kaplan. “I called AHCA and they told me to look the list up on line. When I told them (like many beneficiaries) I had no computer and asked them to send me the information on paper they told me they couldn’t because it is 700 pages long.”

Some providers described many additional burdens in getting needed services approved, and often providing services without guarantee of reimbursement form the plan. “If the person you are talking to is suicidal, we will provide the services they need whether their HMO approves them or not,” said Sheryl Hidalgo of Henderson Mental Health Center. In addition, Henderson staff take it upon themselves to arrange for client transportation to and from medical services, often providing transportation without getting plan reimbursement. “Before, Medicaid reimbursed us. Now plans require that severely ill patients make their own transportation arrangements, which is not realistic, so we try to do it for them,” said Hidalgo.

Yvonne Gamble, a nurse at SOS Children’s Village, a foster care services provider, has approximately 70 children in her care. She referred to “the nightmare of keeping up with what plan each child is in,” as these are constantly changing and many children who are not required to be enrolled have been, because of communication glitches between AHCA, DCF and Child-Net, the various agencies required to keep track of health care for foster children.

All Medicaid Reform roundtable participants reported having received bills for different services, ranging from ambulance transport to specialists' visits to being asked to pay for prescription drugs previously covered under Medicaid.

One person who did not attend the roundtable but was interviewed previously was Janet Barnett. A retired nurse familiar with navigating the system, she was recently diagnosed with carcinoma of the liver. Being forced to choose a plan under Reform, she chose the one that included her oncologist over the one that included her primary care physician. As part of her treatment, she was required to undergo a cath-lab (the insertion of a tube through the artery to detect and repair arterial blockages), because of severe heart murmurs. “The one most important thing people with my condition are warned about is to avoid stress,” said Barnett. “You can imagine the stress I felt when I received a bill from the cardiologist for the procedure because the plan wouldn’t pay for it,” she said.

This was right before having to go back in to receive massive chemotherapy directly to the liver to combat the disease.


(Submitted by Andrew Leone, Florida CHAIN)

We are interested in hearing from Medicaid Recipients in Broward County and Duval County. Please contact us by email at medicaidreform@pobox.com.

www.floridamedicaidreform.org