Tuesday, July 13, 2010
High Copying Charges Block Poor From Their Medical Records
Monday, July 12, 2010
New "Lower Mode" Medical Transport
For the psychiatrically disabled on Medicaid who live in Hunterdon, Mercer, Morris and Salem Counties in New Jersey and who do not drive, transport service is available from the State of New Jersey by which they can get to and from their doctor appointment. The service provider is Logisiticare, a large corporate outfit in Atlanta, GA.
Bookings for this door-to-door service can be made up to 30 days (but not less than two business days) in advance of an appointment. Each time one makes an appointment, one will be asked for the appointment address details and for his or her NJ Medicaid number. (To see the press release about Logisiticare's contract with the State of New Jersey, click here.)
This is another benefit available to those who are on Medicaid, underscoring for the psychiatrically disabled the importance of having their conditions properly and sufficiently diagnosed to qualify for a declaration of disability from the Social Security Administration, which then can authorize payment of Supplemental Support Income, or SSI. SSI in effect becomes a ticket to several disability benefits such as Medicaid, which can then open the door to other benefits, such as non-emergency medical transport services like Logisiticare.
Thursday, July 1, 2010
NAMI National Convention
Now in the fourth year of my psychodyssey, I have evolved from angst and agitation to action. This happens to many who get caught in the maelstrom of mental illness. When you get past the anger, and then the grief, eventually you get to action. So it is that I find myself here in Washington, DC, attending for the first time the national convention of the National Alliance on Mental Illness (NAMI).
It is a big affair, taking over the Washington Hilton Hotel. It has drawn consumers and family members from Alaska to Alabama, from Maine to New Mexico, from South Carolina to California. To see so many other Americans who are navigating as best they cay the storm of the maelstrom is very fortifying. I am not alone.
As a NAMI trained local Family to Family Psychoeducation course teacher, I've spent most of the conference so far attending events relating education. These have involved NAMI's Director of Education, Dr. Joyce Burland, the author of and force behind the acclaimed Family to Family Psychoeducation Course. An elegant, articulate and extraordinary empathetic lady, Dr. Burland has created what is considered one of the most effective evidence-based practices in the movement. By her pioneering work she has also given birth to a movement in its own right--an army of family peer educators who provide incredible relief, solace and information.
NAMI Family to Family, although a course to educate adults, is not an adult education course in the typical sense. In normal circumstances the pedagogy of adults involves motivated, focused, ready adult students. In NAMI's Family to Family, so much is different, because the students are traumatized. They are in shock and despair over what has befallen them. They are emotional bruised and battered. They are depressed, desperate, emotionally wounded. The Family to Family Course presents them with reams of information, but many cannot absorb it in their wounded condition.
Traditional education approaches do not work for them. The course pedagogy indeed is not to point. Just to be with others in the maelstrom, even to review information that itself can also be traumatizing in reminding them of the suffering they wish they could avoid... that is the point, and the value, and the power of the NAMI Family to Family Course experience. I know this now from the two courses that I have taught. I was much fortified and uplifted to be present here with all the other dedicated F2F teachers who know exactly what I do, and who play such important roles in stabilizing families.
Yesterday was education day. Today is legislation day. The convention delegates head en masse to Capitol Hill shortly to advocate for several major mental health initiatives. More about these later. All's well here.
Wednesday, June 2, 2010
New Freedom Commission on Mental Health (2003)
“After a year of study, and after reviewing research and testimony, the Commission finds that recovery from mental illness is now a real possibility.” (Cover letter to the President)
"In 1997, the latest year comparable data are available, the United States spent more than $1 trillion on health care, including almost $71 billion on treating mental illnesses. Mental health expenditures are predominantly publicly funded at 57%, compared to 46% of overall health care expenditures. Between 1987 and 1997, mental health spending did not keep pace with general health care because of declines in private health spending under managed care and cutbacks in hospital expenditures..."
One of the remarkable conundrums I find in my research on The System is how much reference is paid to "hope" yet how little is made to the role that religion and spirituality can play in recovery. There is, I believe, good evidence to support their helpful effects. At a recent NJ State convention of the National Association of Social Workers, I particularly found this to be the case. We do our loved ones a great disservice if we don't promote certain transcendental concepts. One is that we are all God's children, equal and worthy of innate dignity, even and especially the weakest or afflicted amongst us. Another is that hope in its purest sense comes from God. Man will always fall short and disappoint, corrupted as we mortals are by our avarice, our prejudice and our moral limitations. It was not so long ago in a certain Western country which had smashed traditional religious faith that the mentally disabled were classified as "defectives" and put to death because they were not "useful" to society.
It is reassuring to see a government commission state clearly what all desparate families with mentally disabled loved ones have long known themselves from their bitter experiences with The System...
"Of the more than two million adults in the U.S. who have at least one episode of homelessness in a given year, 46% report having had a mental health problem within the previous year."
There seems to be a very high correlation between mentally disabiilty and homelessness.
"A University of Pennsylvania study found that homeless people with mental illnesses who were placed in permanent supportive housing cost the public $16,282 less per person per year compared to their previous costs for mental health, corrections, Medicaid, and public institutions and shelters..."
Doing nothing about it is far more expensive to society.
The whole report takes about an 90 minutes to read. For those of us in the maelstrom, it is worth the time. Download the full report here.
Thursday, May 6, 2010
Schizophrenics Anonymous New Brunswick
In America, they say, there is a support group for everything. Clicking around the UMDNJ website this evening, I found that there is one specifically for individuals with schizophrenia, called, you guessed it, Schizophrenics Anonymous. It was founded in 1985 in Detroit by Joanne Verbanic. Today it is supported by the Schizophrenia and Related Disorders Alliance of America (SARDAA), which, among other things, offers a pretty good resource list. The organization has 150 groups in 31 states and a few other countries.
One of its local groups meets in New Brunswick at a facility apparently attached to the UMDNJ's University Behavioral Health program. The group bills itself as "a confidential SELF-HELP group for persons with schizophrenia or a schizophrenia-related disorder." It meets twice a month on the first and third Tuesdays of each month from 4:00 PM to 5:30 PM at The Self-Help Center - Lower Level, 96 Bayard Street, New Brunswick, NJ. For more information about this group, including a contact telephone number, see: http://ubhc.umdnj.edu/adult/Schizophrenics.htm
Tuesday, April 20, 2010
NJ Medicaid: Where To Find At Least Some Stuff
Just for the record...
The place to find more information about NJ Medicaid is at a nondescript website for the NJ Medicaid Management Information System, located here. But, being a very technical website principally for the use of Medicaid providers, when viewing it the common man would hardly know what it is.
The provisions of NJ Medicaid are found deep within the dense New Jersey Administrative Code. The NJAC can be found through the NJMMIS website which directs you to the New Jersey Division of Medical and Human Services site, which directs you to its Medicaid Eligibility and Services Manuals site, which directs you in turn to a Lexis-Nexis site in which, after you agree to terms, you can look at the long, dense, complicated NJ Administrative Code. For example, want to see what NJ Medicaid says about medications? Look up the "Pharmaceuticals Manual" in the NJAC, under Title 10, Chapter 51.
The list of Medicaid providers in NJ is now online here.
Changes in policies and regulations within NJ Medicaid are catalogued in its newsletter. See all the back newsletters here.
Touchdown! Enrollment Achieved
Done! Finally!
It was almost like filling out a complicated 1040 tax form. So went my disabled son's the enrollment in a new Medicare Part D prescription drug program. But now he is in a new plan, Medco's Medicare Prescription Plan--Value (PDP).
This process began in early February when my son received notice that his Part D plan provider, Fox Insurance, had been disqualified by Medicare. To meet his transitional needs, Medicare took him out of Fox and placed him in one of Medicare's own Part D plans administered by Humana. There was no apparent effect either on his status or coverage.
But Medicare instructed my son to decide, by April 30, whether to stay in the government plan into which Medicare switched him or decide anew on another private sector plan. For the past four weeks we have been trying to determine the linkages of his coverage in whatever plan between Medicare and Medicaid. We learned only yesterday, and confirmed again today, that NJ Medicaid will indeed cover payment for certain benzodiazepine medications that are excluded from the formularies of the six "bench mark" plans for which he as a "dual eligible" was eligible.
This was not an easy process by any means. But we got it done. In most cases I don't think psychiatrically disabled individuals would be able to manage this complicated process alone.
Monday, April 19, 2010
Bingo! (...I think...): The Answer!
The question is...
...when required to switch to a new Part D prescription drug plan, can my son maintain access to all the medications he needs within a plan that covers all their costs as to which he is entitled as a "dual eligible" disabled?
The answer is...
Yes... I think...
But the condition to the answer is...
...as long as NJ Medicare continues to pay for benzodiazepines even when they are not listed in Medicare's Part D formulary.
My quest sought to address two issues: access and cost. As to access, we had to assure that my son could get the medications he needed, without exception. As to cost, could we get the access he needs within one of the "benchmark" plans open to "dual eligibles" like my son?
My quest got off on the wrong track, due to my insufficient understanding. Eaerly on I got confused when misunderstanding that "dual eligibles" in New Jersey had only six plans from which to choose. I thought that dual eligibles were restricted only to these six plans. In fact, they can enter any of the 45 plans available in New Jersey. But they would have to pay those amounts above those payments made by NJ Medicaid.
After more research this afternoon, I finally found my answer. It came from a very knowledgeable call center worker at Medicare and from a very helpful local pharmacist at CVS in my home town.
From my Medicare call center friend, I was relieved to learn that my son's access to all his medications could be assured. Some plans may offer to cover such medications as Medicare will not, but charge a premium to cover their cost. (In fact, Aetna offers a very reasonable plan like this. Aetna's formulary includes all the benzodiazepines which my son had listed, but charged a moderate monthly premium of $7.29.)
I was also pleased to learn--not from NJ Medicaid (or from Mercer County Board of Social Services, the NJ SHIP Counselors, or Social Security's Trenton office, all of which I personally visited yesterday), but from my local pharmacist!--how NJ Medicaid really works. NJ Medicaid apparently pays for benzodiazepines as long as they are correctly prescribed and used, no matter what the restrictions in the formularies of the Medicare Part D providers who are the primary insurers. This means that, contrary to my worry, my son can enter a Part D plan in which his benzos are not in the formulary, knowing that NJ Medicare will cover them after payment is rejected by the primary insurer.
Getting to this conclusion has been exceedingly difficult and frustrating. Part of the problem was my misperception of a note in a yellow form letter from Medicare. But more of the problem is due to the very opaque NJ Medicaid system. Nowhere could I find a posted NJ Medicare formulary. Getting through to the NJ Medical Customer Center was also difficult. Even the helper behind the glass at the Social Security office became exasperated with NJ Medicaid. It was she who suggested that the best person for me to call about NJ Medicaid was... my local pharmacist!
To conclude, then, two questions:
1. Will Medicaid get better or worse with Obamacare?
2. How does a psychiatrically impaired individual navigate such a thing as changing Part D prescription drug plans on his own?
Medicaid Drug Coverage: Who Can Answer My Question?
Ticket to Work: Ticket to Nowhere?
Big News! Feds Postpone 21% Price Cut For Medicare Doctors!
This makes me nervous. The debate around the new health care recently passed talked a lot about some $500 million out of Medicare expenses. The 21% cut was factored into the economics of the bill. This increase immediately busts the cost savings that were predicted in the debate.
Everyone on Medicare, especially our disabled loved ones, should be alert to this issue. How are we to tackle the heavy costs of Medicare? Who can say?
This issue creates a conundrum for me. On the one hand, I am very worried about the out-of-control spending increases within the new health bill. On the other, I am very leery of price caps, and especially price cuts, being imposed on doctors. Too many doctors are already opting out of Medicare, feeling that Medicare's pricing and paperwork are not worth the candle.
Saturday, April 17, 2010
Ask, And Ye Shall Receive... Catholics And Mental Illness
Since tonight I seem to be focusing on how the Catholic Church handles mental illness, I also found a helpful article in U.S. Catholic about the subject, called "Through the Glass Darkly: How Catholics Struggle With Mental Illness" by Anna Weaver. See it at this link.
See also my comment on the article.
Mental Illness: A Catholic Response
St. Dymphna, Patron Saint Of The Mentally Ill
Searching the Internet this evening to learn about other supports for families afflicted by mental illness, I discovered something that I as a Catholic should have sought out sooner. I found out about the patroness saint of the mentally ill, St. Dymphna of Gheel.
Born in Ireland in the 700s, Dymphna was the daughter of an pagan Irish chief named Damon and his Christian wife, who died when Dymphna was an adolescent girl. Overwhelming in his grief, Damon searched the world to find another woman as beautiful as Dymphna's departed mother. But he could find no other like her.
His mind now addled, Damon turned his sights to his own daughter, who resembled her mother in all her beauty. Immeasurably distressed by her now mentally ill father's incestuous entreaties, Dymphna confessed the matter to her priest, St. Gerebernus, and then with him fled Ireland for Belgium, settling in Gheel. Through spies, her father discovered her whereabouts and eventually found her and her confessor in Gheel. Damon beheaded the priest and then once more demanded that Dymphna surrender to him. She again refused, upon which her enraged father killed her.
The site in Gheel where she died is today known for miraculous healings of the mentally ill. In the 1300s, Gheel became the site of a gentle form of deinstitutionalized psychiatric care, whereby mentally ill individuals would be placed in home care with host families. It is also known for a well-known sanitarium for the mentally ill which apparently still stands today.
Sunday, April 11, 2010
Lost... And How To Find: Two Good Products
He didn't know where he was, and we had to find him. But he only had 15 minutes of battery time left on his cell phone. We didn't have the GPS function active on his cell phone. And the police couldn't track him on their radio waves without a judge's consent, which would have taken three hours. In the end, I had to phone-coach my son, even though inebriated, to drive (carefully!) back to a place where we could pinpoint his location of a map. Thank God he was able to do that (without getting arrested), and thank God we were able to rescue him safe and unharmed.
Wednesday, April 7, 2010
Wrestling With The Long Arm Of The Law
Families with mentally ill loved ones are no strangers to the legal system. Whether through abuse of substances or acting out in the midst of relapses or just accidentally, too often our mentally ill loved ones run afoul of the law. This can be one of the most harrowing experiences a family can experience.
The National Alliance on Mental Illness, New Jersey State chapter, has published a helpful pamphlet to help families navigate the legal system after, and before, problems occur.
See it here.
Housing... Another Waiting List Update Demand
But! Local PHAs give preferences to their own local citizens. The available slots are rare, rare, rare. All one can do is apply to get on innumerable wait lists, keep a watch on them, and be ready to respond immediately when notices come your way. Most of such notices are merely waiting list updates. Failure to respond to these may result in being dropped altogether.
- Social Security Cards and Birth Certificates for yourself and each person listed on your application.
- Verification of any and all income such as Employment, TANF, Child Support, SSI/SSD, VA Benefits, Unemployment and any other form of income that is received which may not be listed.
- For Employment, your employer must mail or fax all wage information. It should state your rate per hour and the hours you work per week and /or your annual salary.
- If homeless, a third-party verification from a public or private facility that provides shelter for homeless individuals, the local police department, or a social service agency, certifying the family's homeless status.
- If substandard, provide a third-party verification from a government agency or present landlord indicating substandard conditions existing at home (such as no lights, no running water, etc.). If required, you must provide entrance to your home by one of the Admissions and Occupancy staff to investigate the substandard conditions.
The applicant must have an annual income that does not exceed the low-income limits established by HUD. These income limits are posted in all THA offices and below:
Monday, April 5, 2010
Tax Time... Even For The Disabled
Wednesday, March 31, 2010
Double Trouble: A Good Presentation On Co-Occuring Disorders
Many of our loved ones who struggle with mental illness also suffer from a co-occuring substance abuse disorder. This can be "double trouble". It has been for my son. But now he's been clean for about a month now. He's making progress.
I am always interested in seeing new information on this terribly vexing problem. Here's a good presentation by Hazeldon and WestBridge Community Services. I am particularly fond of WestBridge, which my son attended for a while. It does a very good job in treating dual diagnosis cases.
Here's the presentation, a slide show. (Be patient. It's a big file and will take a little while to load.)
Thursday, March 25, 2010
SHIP 3: Got The Appointment... For 7 Days From Now
Still working on my son's Medicare Part D prescription drug insurance...
Background: My son's previous insurer, Fox Insurance, was kicked out of the Part D program by CMS, the Medicare administrators. So he has to find a new plan. Before he can determine which is the best option, he must determine how any of the prospective plans interface with NJ Medicaid, under which he is also covered. My research determined that there is a State Health Insurance Counseling Program, called SHIP, funded by Medicare, that can help him with that. Earlier this week I had spoken to the SHIP Coordinator for Mercer County, who was to help me get an appointment with a SHIP Counselor.
Today I spoke with The counselor she had in mind for my son isn't available. So we've scheduled for my son to visit with another counselor, on March 31.
I'm looking forward to the appointment. I am observing, however, (and not yet judging) how long it is taking to get from the decision to get help with the Medicare-Medicaid interface to the time it actually will be offered. From the time we began seeking a change in his plan to time we discovered through research of SHIP's existence: 2 days. From the time we were offered an appointment with a counselor until the time one was available to see us: 7 days. This is itself perhaps is not so extraordinary, especially when working with agencies in which the workers are certified volunteers. There must be a relative scarcity of such qualified counselors. Hence the time it takes to get an appointment. Kind of like a doctor... I am keeping track of this initiative and all my son's other various initiatives on a master to-do list, managing from it every day like a regular job. One has to keep on top of such things.
But can a mentally ill loved one with a thought disorder manage this process on his own? The complexities of Medicare and Medicaid? Finding out that there is a SHIP and what it does? Finding the right person to call? Learning the process of getting an appointment with a counselor. Getting that appointment seven days later? There's a lot to keep track of. Can this system be made more simple or direct? How will this be after ObamaCare is implemented to include 30 million more people on the Medicare/Medicaid roles? I don' t think our waiting times for appointments will be reduced...
Tuesday, March 23, 2010
More About SHIP: My Conversation With The County Coordinator
Wendy told me that her position as the Mercer County Representative for SHIP is funded through grant from the Centers for Medicare and Medicaid Services, or CMS, which is channeled through the NJ Department of Health and Human Services. As the County representative, Wendy doesn’t actually serve clients directly. She coordinates volunteer counselors who are certified by CMS to provide help to seniors and disabled who need help enrolling in their Medicare plans. She took down my son’s information and will pass it on to one of her counselors who will get back in touch with me. There are apparently certified counselors throughout the County.
The certification process is apparently intensive. Candidates gather for a five day training course, then take an at-home examination. After they are certified, the volunteers meet again quarterly at local locations during the year for refresher courses. They then engage with Medicare recipients during the open enrollment period from November 15 to December 31 to help them navigate through the shoals of the Medicare enrollment system. These training programs are run by the SHIP Coordinator for the State of New Jersey, Ms. Deborah Breslin, who has run the program for the last 13 years.
Mental Health Parity in Medicare: Putting The Law Into The Regs
I. SUMMARY OF CHANGES: Section 102 of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 amends section 1833(c) of the Social Security Act (the Act) to phase in a 5-year reduction to the payment that Medicare patients are required to make for outpatient mental health services that are subject to the outpatient mental health treatment limitation (the limitation). Payment for outpatient mental health services will gradually reduce from 2010-2014. Effective January 1, 2014, the limitation will no longer exist and Medicare will pay outpatient mental health services at the same level as other Part B services. Hence, the limitation will change as follows: 2009 and prior years=62.5 percent: 2010-2011=68.75 percent; 2012=75 percent; 2013=81.25 percent; and, 2014 and onward=100 percent.
Monday, March 22, 2010
SHIP: State Health Insurance Counseling and Assistance Program
OK, I found out what SHIP really is.
It is a program linked to Medicare, but not controlled by it. See this link.
In New Jersey, it is a program run by the NJ Department of Health and Human Services. See this link.
The SHIP Counselors are distributed around the State, by county. See this link.
In my county, Mercer County, the SHIP Counseling franchise is held by a private agency called Family Guidance Center Corporation. See this link.
Tomorrow I'll see if I can get through to the lady who is the Mercer County SHIP counselor.
Bureaucratic Encounter with NJ Medicaid: My Son's Future Under Obamacare?
Although Medicare Part D offered my disabled son a choice of 45 prescription drug providers, only one of these included in its formulary all the medications he is using or might need. But the one program requires payment of a monthly premium. Given my son's "extra help" status with Medicare, he has been entitled to have NJ Medicaid pick up all that Medicare does not pick up, such as premiums, co-pays, and payments beyond caps and in the Part D "doughnut hole".
So I got to wondering... Does NJ Medicaid cover those costs such as premiums that Medicare plans would require of my son?
I called the NJ Medical Hotline at 1-800-356-1561. As I worked myself through the recorded messages to the destination I wanted, I reflected on last night's vote in Washington for Obamacare, which would extreme Medicaid coverage to several million more people. Here was an initial test of the Medicaid system. How responsive would it be? How friendly? How effective? I went on hold at 2:54 pm.
Medicaid On The Phone
At 3:01 pm, a woman curtly answered. "Medicaid!" I asked where I might be directed to get the formulary of medications available from NJ Medicaid. "Well," the female voice responded, "I know that there are certain medications that Medicaid no longer pays for." Such as what, I asked. "Asthma. Medicaid no longer pays for asthma medication." Well, that is an issue for my son, since he has asthma. But that wasn't the purpose of my call. I repeated my question.'
"Where can I find the formulary of prescription medications offered by Medicaid?"
"Just a minute. Let me put you through to our pharmacist."
A Dr. Yablonksy came on the line. Dr. Yablonsky spoke with a distinct New York accent and a mildly aggressive tone.
"Speak up!" he said. "I can't hear you." I channeled my voice directly into the mouthpiece as repeated my question: does Medicaid have a printed formulary, and where can I find it?
"Medicaid has no formulary. A pharmacist will bill Medicaid directly."
We were not communicating too well, it seemed. So I tried to explain my son's ailments.
"Call Unisys, the fiscal agent for NJ Medicaid at 609 588 3397. Maybe they can answer your question. What kind of medications are we talking about here?" asked Dr. Yablonsky.
I mentioned the anti-psychotics like Geodon and benzodiazepines like Clonazepam (Klonopin).
"Benzodiazepines might require a prior authorization. The doctor would have to call first. Unisys gives the prior authorizations. Call Unisys."
Unisys On The Phone... Not.
So I called the number that Dr. Yablonsky gave me. A man named Jeff answered. I repeated my son's dilemma.
"No, Medicaid will not pay the premiums of Medicare Part D plans that require them. Only the "benchmark" plans require no premiums. And no Medicare Part D plan will cover benzos..."
This initial response sounded a little disjointed and not quite correct.
"Well," I countered, "we have actually found that one of the 45 suggested plans will cover his benzodiazepines. But that one, Aetna Rx Plus, requires a monthly premium. That's one of the reasons I am calling: to see if Medicaid helps a covered individual pay for such premiums."
"No, it doesn't," said Jeff. He paused. "Medicaid will cover benzodiazepines as a "wrap around".
Wrap around? "What's a wrap around?" I asked.
"It means that Medicaid pays."
I was still a little confused. I wondered whether I might be able to see something in print about all this. "Does Medicaid have a posted formulary somewhat, as do Medicare Part D prescription drug plans, right on Medicare's website?"
"Medicaid has no formulary", Jeff tersely replied. "If a drug is not covered by Medicare Part D, Medicaid usually doesn't pick up."
"Except for benzodiazepines, as you just said?" I asked cautiously. "Right. Except for the benzos. But prescriptions have to billed to Part D first."
Another pause.
"You know what?" Jeff said, "Talk to the SHIP counselor at the Local County Board of Social Services. They can help your son pick a Medicare Part D plan.
This seemed a strange suggestion from someone at Unisys whom Dr. Yablonsky had told me administers the NJ Medicaid program. "No, I'm not with Unisys," Jeff clarified. He was a pharmacist in the Division of Medical Assistance and Health Services, part of the New Jersey Department of Human Services.
Hunting Down The SHIP: Call to Mercer County Board Of Social Services
I called the Mercer County Board of Social Services. The recording identified the number as the screening line. To be screened, I was asked to leave a recording or go personally to the Trenton office. That wouldn't do. I then called another number offered by the recording, 989 4491, "to speak to your worker directly". I called it to speak to Mr. Holloway in Section F, who has helped my son before. His recorded voice answered and asked for me to leave a message. It also gave me another number "in case you need to speak to someone immediately". So I called that number. As it happened, Mr. Holloway answered that line! Good!
Again I described my son's situation.
"You have to speak to someone in Medical. That's a whole different department." What he meant by "Medical" was the Medicaid Department of the MCBOSS. [Note: All Medicaid cases in Mercer County, except for those on General Assistance (Welfare) or those like my son on SSI are handled by the 11 workers in this department. -Ed.] Mr. Holloway then transferred me.
"Medicaid. Mr. Fultini speaking". Another person. I began my explanation. Before I could finish, Mr. Fultini told me that I would have to speak to the Social Security Administration. I immediately countered to say that the matter is not about how my son got his Medicaid, but how Medicaid co-ordinates with Medicare. I explained that someone in the Medicaid pharmacy at Division of Medical Assistance (Jeff) said that I should speak to a SHIP counselor.
"What is a SHIP counselor?" I asked. "When they first came out with Part D," Mr. Fultini began, "they had some people helping the transition..."
"Who runs the SHIP counselors?" I asked.
"I'm not really sure," said Fultini. "I think it is another division of the State Let me find out. Sorry to put you on hold again." So the phone went quiet while he looked for the information.
He came back on the line. He gave me a number in Princeton, 609 924 2098 x14, someone sponsored by the NJ Department of Health and Senior Services. They are counselors for the general public to coordinate Medicare matters. "By the way," Mr. Fultini reported, "SHIP stands for State Health Insurance Assistance Program."
Call to SHIP
I then called the number Mr. Fultini gave me. "Family Guidance", a woman answered. It turns out that I had reached the Princeton office of Family Guidance, a private social services agency that had recently merged with the Family and Children Services. I asked to speak to the SHIP Counselor. "Oh, you need to speak to Wendy Polsen. She's not in today. She's at a seminar. Can you call back tomorrow?"
Well, we're still not finished. So many calls. So little progress. My God. Is this the future under Obamacare?
Sunday, March 21, 2010
Medicare Part D: Is What I Need In The Formulary?
My son's pharmacy called the other night. The pharmacist wanted to know the details of my son's new Medicare Part D drug plan. Even though he is 24 years old, my son participates in Medicare Part D, and Parts A and B well, because he has been declared disabled by the Social Security Administration because of his schizophrenia.
I took the call. "What are you talking about?" I asked.
"The insurer needs to know your son's Medicare number," responded the lady pharmacist.
"Wait a minute. His prescription drug company already knows his number. Who is asking for this?" I countered.
"Humana, the plan administrator," came the answer.
"What? His plan is with Fox Insurance, not Humana!
"Well," said the pharmacist, "it seems that Medicare has changed his prescription drug plan."
Now I was worried.
Medicare Changes My Son's Plan, But With Good Cause
What happened? Fox Insurance apparently ran afoul of the Medicare system, and so Medicare apparently disqualified it with immediate effect from participating as a Medicare Part D provider, as explained in the recent press release of the Centers for Medicare and Medicaid (CMS). It is the first time in its young history that the Medicare Part D program has banished one of its approved providers.
Actually, I'm pleased by this action. I appreciate that a CMS audit has ratted out Fox. My son's interactions with Fox over the past year proved it to be a squirrely outfit. Good riddance to it.
But the change now requires my son to begin anew the process of selecting a new prescription drug provider. That means having to hassle with the clunky Medicare website.
Clicking around in Medicare.gov
Medicare has a reasonably serviceable website. It is clunky to the extent that it doesn't easily loop back and forth, but requires a rigid linear approach. Several times in processing my son's medications information, I had to start the process over at the beginning, entering in his ID and password again and again. But eventually we got it worked out.
The challenge for my disabled son is to find a prescription plan that does two things: keep costs down (to zero, if possible, since he is technically indigent) and find a plan formulary that includes all the medications he needs (including the controversial benzodiazepines he needs to reduce anxiety caused by his schizophrenia).
After he listed all the medications he currently needs and could possibly need to address psychosis, depression, anxiety and ADHD, Medicare.gov researched all its providers and came up with 45 possible plans for my son's consideration. That looked encouraging. But a closer look revealed that only seven plans has no required premium payment. But none of these included all the required medications. As it happened, only one of the 45 suggested plans, Aetna Medicare Rx Plus (PDP) included all my son's medications in its formulary. But it also required a monthly premium of $7.90. That may seem a pittance to a regular person. It is not inconsequential to an SSI and SSD recipient living on $695 of monthly revenue and monthly rental expense of $388.
Well, we have to check one more thing: would NJ Medicaid cover the premiums that a Medicare Part D plan might require. I suspect it will, since my son is deemed totally disabled. But this will require a call to NJ FamilyCare which administers NJ Medicaid, which does not maintain a comparably serviceable website.
So, it is not easy for the psychiatrically disabled when Medicare has to change your drug plan...
Friday, March 19, 2010
Court Date: Consequences Of The Relapse
Last Monday my son went to court. I tagged along. He went to answer two misdemeanor charges issued to him during his blacked-out relapse bender now three weeks ago, just before he was admitted to the Emergency Room with a Blood Alcohol Content nearly five times the legal limit. The case offered an opportunity to encounter The System in its legal guise at the local level. We also learned about seeking out a court-appointed attorney.
The charges were Disorderly Conduct and Harassment. My son somehow wound up in the kitchen of a local downtown restaurant during dinner time, entering from a service alley through the back door. The restaurant owner called the police. When they saw my son, the police called for an ambulance. As the police and EMS were trying to get him in the ambulance, my son launched a swearing tear, tongue-lashing the cops and the two lady EMS drivers. My son doesn't have any recollection of this episode at all.
Court-Appointed Attorney?
Before appearing before the municipal judge, my son first spoke with the prosecutor, who had not read the police report, but first asked if my son had a lawyer. When my son said no, the prosecutor asked if he would like to have one appointed to him. Given his indigent status as an SSI and SSD recipient, my son was theoretically entitled to have one. He said yes.
Back he went to the judge, who gave him an application to complete stating his financial status. With his meager personal income just about equaling his meager expenses and no assets besides a car, my son qualified financially. But as it turned out the charges would only permit the engagement of a court-appointed attorney if there was to be a "consequence of magnitude." The judge turned to the prosecutor and asked what he would seek a "consequence of magnitude". In other words, was the prosecutor seeking a jail sentence?
"My God!" I whispered under my breath. Would he really seek a jail sentence for my son?
Thankfully, my anxiety was quickly dispelled when the prosecutor confessed, while now quickly scanning the police report, that jail was probably not necessary in this case. There had been no physical contact. No one had been hit or harmed. He also surmised that there might be something more behind the case that perhaps he ought to explore further with my son before recommending a consequence. The judge agreed. She directed the prosecutor and my son to step out into the hallway to work something out.
Working Things Out
The prosecutor read through the report more carefully and asked my son what happened. Having blacked out, my son couldn't remember, but he did confess that he had been drinking heavily. He then explained his recent treatment at Princeton House, without going into too much detail. He also described his previous challenges with substance addictions. The prosecutor now understood better the situation. He proposed two options to my son.
If he wanted to settle the case that day and been done with it, my son could plead guilty and pay a fine. That would create a mark on his record, but it could be expunged after five years upon my son's initiative to get it expunged. The alternative was to dismiss the case, subject to the court receiving testimonial letters. One would have to report a professional evaluation of my son by a licensed drug and alcohol counselor. The others would be letters from both his psychiatrist and psychologist that he was complying with their recommended regimens (which he is). If that course was agreeable, the prosecutor would ask the judge to postpone resolution of the case one month, pending receipt of the letters.
Good Outcome
The choice was simple: go for the dismissal. In short order, they were back before the judge to explain their agreement, and the judge agreed to postpone the case. This was a very good outcome.
No one likes to go to court. It is especially hard for someone with a mental disability. As a father, I was worrying about possible harsh, awkward or embarrassing handling which might to further stigmatization. In this municipal court, the process went better than expected. The judge and prosecutor, though business-like, sensed the underlying situation and led the case in a good direction, while also treating my son in a regular and respectable way. In this case, The System was benign. Thank God.
Home Care Psych Nurse: Mercer Street Friends
Mercer Street Friends is well known as a local purveyor of donated food to needy people. Its Food Bank serves nearly 40,000 people in the area.
For the psychiatrically disabled, Mercer Street Friends also has a home care behavioral health service. It employs two psychiatric nurses, one an RN, the other an LPN, who will make periodic home visits to psychiatrically disabled at their homes. In their visits, they provide medications advice, counseling, coping skills education, and other services. Their clients tend to be "stable", meaning compliant with medications and not actively psychotic.
I called to see if their service was one from which my son might benefit. I am keen that my son, now at home with us as he continues his recovery from relapse three weeks ago, be touched by as many resources as possible, especially since he does not do well in group therapy settings as are common within partial hospitalization (full-day) or intensive outpatient (half-day) programs. That they come to the place of the disabled is like the service of the PACT Teams, although the Mercer Street Friends nurses visit less often, more on the order of once every two weeks and not every day, like PACT.
As it happens, Mercer Street Friends is not allowed to offer its home health care service in my town of Princeton, even though it is in the same county. The regulating agency for home health care agencies in New Jersey apparently issues Certificates of Need enabling only certain agencies to serve certain areas. Thus Mercer Street Friends provides this service in Trenton, Ewing, Hopewell, Pennington, Hamilton, and Robbinsville, but not East Windsor, West Windsor, Hightstown, or Princeton. I was told that the Certificate of Need in Princeton for home health care is with Princeton Home Care, a division of the same hospital which manages Princeton House Behavioral Health. But Princeton Home Care does not offer the same psychiatric home-based outreach as Mercer Street Friends. This constitutes a minor but annoying aspect of The System: a specific psychiatric service that is available from one agency in the county is not available from another in the same county, even though both are regulated and funded by the same government agency. Go figure.
Anyway, Mercer Street Friends is a very good outfit. Its home health care psychiatric nurses might be just the ticket for a home-bound or isolating loved one with a mental illness who is compliant with meds and otherwise stable, but needing a little extra support.