More About SHIP: My Conversation With The County Coordinator

Aspect of Need Addressed: Medical, Financial

Picking up my search when I left off yesterday, this morning I spoke to Wendy Poulsen, Mercer County coordinator for the SHIP program. My objective is to learn more about the interface between Medicare and Medicaid to help my son enroll in a new Medicare Part D prescription drug program, now that his previous provider, Fox Insurance, was disqualified by Medicare. (See my previous post of this.)

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.

So, I'm still haven't arrived at the destination of this search. But I'm closing in on it. At least now I know where I will likely end up.

Mental Health Parity in Medicare: Putting The Law Into The Regs

Aspects of Need addressed: Psychiatric, Medical, Financial

Last year the mental health community reached the promised land of Mental Health Parity when President Obama signed the Stimulus Bill to which the measure was amended. This made mental health care reimbursable by insurance companies at the same rate as regular medical care. This was a major step forward.

Now we have one segment of the regulations that will implement this legislation, courtesy of Open Minds, an excellent online information source for mental health issues.

Not that I have a lot of time to do so, but I like to read--or, should I say, try to read--such regulations to see how complex all of this can become. It offers a harbinger of what might be ahead with the implementation of ObamaCare.

Here's the summary:

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.

Got that? Here's the link to the full text of this enacting regulation.

SHIP: State Health Insurance Counseling and Assistance Program

Aspects of Need Addressed: Medical, Financial

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?

Aspects of Need Addressed: Medical, Financial

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?

Medicare Part D: Is What I Need In The Formulary?

Aspects of Need Addressed: Medical, Financial

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...

Court Date: Consequences Of The Relapse

Aspects of Need Addressed: Legal

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

Aspect of Need Addressed: Medical, Psychiatric

The other day I picked up a brochure at NAMI Mercer for Mercer Street Friends, which is an active social service agency in the Trenton area. Mercer Street Friends is a Quaker-affiliated, nonsectarian human care organization working to provide compassionate and practical solutions to the problems of poverty.

Inspired by the Quaker spirit and recognizing the inherent worth of all people, it is dedicated to the creation of a nurturing environment in which individuals may achieve independence, community, and quality of life. It's a pretty big outfit. Revenues as recorded on its 2008 Form 990 were $11 million, of which about $3 million comes from government sources and $5 million from program revenues.

(Mercer Street Friends is the service arm of the Quaker meeting by the same name of long standing in Trenton dating back to the late 1600s. If you have a Quaker heritage or interest in the early Orthodox Quakers who settled West Jersey region, the short history of the Mercer Street Friends is worth your time.)

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.