Welcome to The Issachar Project!

I created The Issachar Project in 2009 to provide parents, advocates, attorneys and practitioners with a source of information about Medicaid, the EPSDT benefit and successful behavioral intervention strategies for treating children in their homes, schools and communities.  Now, the Issachar Project is moving into high gear with the publication of my book THE ISSACHAR PROJECT set for May 25th in conjunction with my presentation at AutismOne in Chicago the following day. The Issachar Project will present questions to State Medicaid Agency personnel regarding the availability of EPSDT funding for behavioral treatment programs in all fifty US States. With the answers to these questions, it will be possible for a parent to strategically navigate the dark waters of the EPSDT system in any State in a search for honest and compassionate government employees. They do exist, but it’s really disheartening to wade through the system until you find one, especially without a map.

The mission of The Issachar Project is to provide that map, individualized for every state. It will be updated no less than once yearly and maintained in an on-line database, supported by philanthropy. With this map, parents will be able to quickly identify

•  The correct forms to fill out, how to fill them out and where to send them to enroll a child with a disability in the Medicaid system in that State.

•  If the State has implemented the “Medically Needy” category of Medicaid eligibility as a matter of State law, then virtually any child under the age of 21 who has a disability can enroll in Medicaid in that State, but the enrollment form has to be specially marked for this category.

•  The key people in the State who “know the truth” about EPSDT funding and how it is administered in that State to provide funding for Behavioral Health Rehabilitation Services (in addition to dental & lead level screenings and the other better-known portions of the EPSDT mandate).

•  The names and contact numbers for the Medicaid Managed Care Organization(s) in the family’s catchment area that will be involved in the overseeing of the child’s EPSDT funding, and the “best practice standards” that they espouse.

•  The names and contact numbers for the Medicaid Enrolled Practitioners within the family’s catchment area that are now, or could be, involved in delivering EPSDT funded Behavioral Health Rehabilitation Services to the child. We will assess their “track record” based on national standards of practice and a review of training and treatment documents, State performance assessments, audit and criminal investigation records and other material that may be submitted by parents.

•  The names and contact numbers for “licensed practitioners of the healing arts” who are not yet enrolled in Medicaid within the State who may be interested in working with The Institute for Behavior Change to create a “Medical Home” within a pediatric or family medical practice that will have a strong Behavioral Health component. With help from the Institute for Behavior Change in regard to staff recruitment, training and monitoring, it is possible for any medical practice in any State to implement Effective Treatment in a Wraparound Cup® as efficiently and successfully as The Institute for Behavior Change has done for the past 20 years.

Steve

Stanley Mrozowski leaves the PA Children’s Bureau.

The following statement was issued by the RCPA organization that has worked closely with Mrozowski for several years.  It does not offer any explanation as to why “the decision has been made to make a change” at OMHSAS that included Mrozowski’s departure from the PA Children’s Bureau which developed into the central planning and implementation point for Behavioral Health Rehabilitation Services (BHRS) throughout Pennsylvania under Mrozowski’s leadership.

On Friday (September 18), Stan Mrozowski informed RCPA staff and others that he had relinquished his position as Director of the Children’s Bureau at the Office of Mental Health and Substance Abuse Services (OMHSAS). Dr. Mrozowski noted that “there have been discussions recently in the Department of Human Services about the role of the Bureau and the decision has been made to make a change.” In his farewell message, Stan noted that “I leave with immense satisfaction about the many accomplishments over the past 12 years during which I have been the Director of the Children’s Bureau. I have very few regrets – mostly only that we did not do even more to help children and families in the Commonwealth. I also leave with appreciation for having worked with so many fine people who truly care about youth and families. I will truly miss the friendship and the collegiality that has made the work so rewarding.” RCPA will follow up with OMHSAS leadership to explore and report on any other changes that are planned for their management of children’s behavioral health services in the future.

Hopefully, desperately needed improvements in the BHRS system will now move forward.  These include streamlining the BHRS provider enrollment process to expedite the admission of qualified BHRS practitioners, establishing a standard of responsiveness to provider inquiries especially to appeals for State Medicaid/BHRS policy clarification, and the issuance of a final version of the “BHRS Draft Bulletin” that has been languishing in perpetual draft form since March of 2013.
Steve

 

Celebrating the start of the 20th year of operation for the Institute for Behavior Change

The Institute for Behavior Change will celebrate the start of its 20th year of operation in October. This short program describes the unique approach we have created to the training of Specialists in the Treatment, Evaluation, and Education of children with mental illness symptoms and behavioral challenges. I am proud and thankful beyond words to be associated with the terrific group of professionals we have assembled to carry on our work.

https://www.youtube.com/watch?v=hYkVWGpMd6E

Steve

CMS-2390-P requires comments from parents, professionals and advocates

In response to my 6/25/2015 appeal for comments to CMS-2390-P (especially the section that explains how the parents of disabled children can be held financially responsible for the repayment of the cost of treatment delivered to their disabled child if they lose the final appeal of a Managed Care Organization’s denial of funding), I received the following e-mail message from an advocate.

Steve, 

The federal regulations have long allowed states to recoup the cost of services provided pending appeal if the family loses the appeal.  See 42 CFR 431.230.  Thankfully, Pennsylvania has never, to my knowledge, taken advantage of this provision.  The proposed regulations and commentary say that if states choose to take advantage of this long-standing provision, they should say so in the MCO contracts and be consistent between FFS and managed care. 

The proposed regulations you refer to are very lengthy (with the commentary, several hundred pages), and cover many, many, important topics.  If [our organization] submits comments on them and urges others to comment, I will let you know.

My reply

Thanks for the clarification but the CMS requested comments on 438.420 (which affirms the appropriateness of making the recipients of services financially liable if they lose the final appeal).  That’s wrong, no matter how long it’s been “on the books.”  CMS could fix 431.230 if they felt compelled to, and that’s why the comment process is so important.

Slavery was “on the books” for 87 years before it was challenged and finally repealed.  Some people still think that was a mistake.

It is wrong to hold the parents of a child who is a Medicaid recipient financially liable for the cost of the treatment services provided to their child while an appropriate, conscientious appeal of an adverse funding decision is underway.  Perhaps that’s why Pennsylvania has never done it.  They know it’s wrong.  I know it’s wrong.  The comment period is the place to express outrage over it, no matter how long it’s been “on the books.”  Evil doesn’t improve, or stay the same, with age – it gets more dangerous as time passes because it can spread.

This comment period is the time and place to put an end to the evil threat of making parents of Medicaid recipients financially liable while they are fighting for the lives of their children.  It should have been stopped, no matter which section(s) it appeared in, many years ago.  Don’t you agree?

Steve


Here is a link to the CMS-2390-P proposed rule changes.  You can see the 8 comments I’ve uploaded there so far, and the 23 comments received thus far (more than 600 comments were received the last time CMS proposed major changes to the Medicaid Act).  The present set of changes is lengthy, but it is at least as important as the set of changes that received over 400 comments by this point in the two-month comment period (which expires on July 27th).  This set of changes is flying way, WAY under the radar:

http://www.regulations.gov/#!docketBrowser;rpp=25;po=0;D=CMS-2015-0068

URGENT! Comments needed on proposed Medicaid policy changes that will hurt Millions of people

The rate of comment submissions regarding proposed Medicaid changes (2390-P) has increased 75% but there are still just 23 comments posted. By this point in the comment period for a previous CMS proposed rule change, there had been over 500.  This new set of rule changes is flying way, WAY below the radar, unfortunately, and millions of people are going to suffer because of it. Millions.

One esteemed Pennsylvania advocacy organization representative lamented to me “Steve, the thing is just too big — it’s over 200 pages in the Federal Register”). How could 200 pages be considered “too heavy to lift” by an advocacy organization? Here’s just one example of what is at stake; this is an excellent example of the kinds of comments that will expose awful changes that will go into effect Nationwide unless they are reformed – via the Comment process:

“This is absolutely unacceptable. I can’t believe this revision calls for “making recipients pay if they lose an appeal”. You are talking about poor people, most of whom are disabled and you want THEM to pay if they lose an appeal? This is how the rich get richer and the poor get poorer. I almost thought it was a joke when I heard this. Is this an attempt to stop all grievance filings? There is a point where the people need to realize that the government is no longer working for the people. This “revision” will hinder access to quality medical care for the disabled. How low can we go here? I am absolutely stunned by this and I hope that our system is not this far gone. We are a wealthy nation, how does it look when corporate subsidies are given out like candy and the disabled are left to beg for medical care. Just remember how this great nation was founded. The American people are growing weary of your antics.” (thanks, Sarah)

Here is a link to the CMS-2390-P proposed rule changes.  You can see the 8 comments I’ve uploaded there so far:  http://www.regulations.gov/#!docketBrowser;rpp=25;po=0;D=CMS-2015-0068

CMS affirms that parents can be held financially liable during appeals of MCO funding denials

The Centers for Medicare and Medicaid Services issued a Proposed Rule (#2390) a few days ago.  The comment period ends on July 27th.  You can read the 8 comments I’ve sent them so far by clicking here:  http://www.regulations.gov/#!docketBrowser;rpp=25;po=0;D=CMS-2015-0068

When you read my comments, you will see that there are some very good things planned in Washington for the States to comply with, and some absolutely dreadful things that the CMS wants to do to Medicaid recipients.  Please read these comments and distribute them to others if you think it would be helpful.

Of particular importance is the plan to make Medicaid recipients “assume financial risk” for filing appeals of “adverse decisions.”  In other words, if a parent appeals an awful decision by a MCO reviewer, and the Administrative Law Judge rules against the parent in a Fair Hearing, the parent would then be obligated to repay the funds spent on delivering treatment to their child during the grievance period.  Seriously.  What parent would consider filing a grievance if they were told that they’d have to pay back the money billed by their service provider for treatment during the appeal process?  Nobody in their right mind, right?  Especially with the incredibly random draw that happens with Administrative Law Judges and how they misread, misinterpret or ignore the law they’re supposed to be upholding.  I have three recent Fair Hearing transcripts that document how perfectly documented evaluations, prescriptions and treatment plans are dismissed by the highest authorities in Pennsylvania’s Medicaid program using the code “failed to meet medical necessary criteria” when that claim is patently and demonstrably false.  I’m writing a screenplay using those hearings as the foundation; the production will be “based on true events.”  Think of “Judgment at Nuremberg” and you’ll get the gist of what I’m working on.

This business of “making the recipients pay if they lose an appeal” will not just have a “chilling” effect on grievance filings, it will freeze them out entirely.

There’s more.  Please have a look at the comments and you’ll see.

Here is a link to the CMS-2390-P proposed rule changes and comments submitted so far.  http://www.regulations.gov/#!docketDetail;D=CMS-2015-0068

Will a Medicaid MCO violate Federal laws & State Regs to gag providers?

Here are the rules.  The question now is, will the Pennsylvania Medicaid Managed Care Organization that proposes to prevent its treatment providers from being advocates for their clients actually put their proposal into effect?  They claim that advocacy “is not the provider’s responsibility” but that flies in the face of the law.  Will they violate two Federal laws and State Regulations to gag providers who want to be (and could be) effective advocates for their clients, especially in Grievance hearings (when the MMCO denies necessary funding and the parent of a disabled child needs all the help they can get to thwart those misguided intentions).  Here are the laws; judge for yourself if providers of treatment can be punished, sanctioned, or thrown out of a Medicaid Managed Care Organization’s provider network for providing advocacy for their clients.

******************

42 CFR 438.102(a)(1) states an MCO, PIHP, or PAHP may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient [emphasis added], for the following:

  • The enrollee’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered.
  • Any information the enrollee needs in order to decide among all relevant treatment options.
  • The risks, benefits, and consequences of treatment or nontreatment.
  • The enrollee’s right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions.

Further, 42 CFR 438.402(b)(ii) states a provider, acting on behalf of the enrollee and with the enrollee’s written consent, may file an appeal. A provider may file a grievance or request a State fair hearing on behalf of an enrollee, if the State permits the provider to act as the enrollee’s authorized representative in doing so.  Please note:  The State does permit it.

PA’s Program Standards and Requirements states, in order for the provider to represent the member in the filing of a grievance, the provider must obtain the written consent of the member.   A provider may obtain the member’s written permission at the time of treatment.  A provider may NOT require a member to sign a document authorizing the provider to file a grievance as a condition of treatment.  The written consent must include:

  • The name and address of the member, the member’s date of birth and identification number,
  • If the member is a minor, or is legally incompetent, the name, address and relationship to the member of the person who signed the consent,
  • The name, address and plan identification number of the provider to whom the member is providing consent,
  • The name and address of the plan to which the grievance will be submitted,
  • An explanation of the specific service for which coverage was provided or denied to the enrollee to which the consent will apply, and
  • The following statement: “The member or the member’s representative may not submit a grievance concerning the services listed in this consent form unless the member or the member’s representative rescinds consent in writing.  The member or member’s representative has the right to rescind consent at any time during the grievance process.”