Posted 10/28/2012 10:19 PM (GMT 0)
This is the latest on Insurance.
Florida Republican Governor Rick Scott and the legislature are looking for ways to control costs. Healthcare is on their list of areas to control. Governor Scott has turned down federal funding to expand Medicaid in Florida and has required those who qualify for their current program to join managed care options organized by districts. There are a few who qualify for continued Traditional Medicaid (children and certain sick adults with AIDS and Hemophelia. There are programs for the elderly, mentally and physicall challenged as well).
My partner was also in a protected group during his transplant work up and surgery. After about a year he was required to join a managed care program. This started September 1, 2012.
Medicaid is funded annually, July 1 – June 30 th .
Patients in the managed care programs have limited services:
Please note this is my interpretation of a 118 page manual from the Internet www.ahca.myflorida.com/Medicaid/flmedicaid.shtml , plus a narrative of personal hurdles, and is not legal information. Always check your own state and/or local program for accuracy)
· All care must be managed by a participating Primary Care Physician.
· Emergency Room visits are limited to 6 per year and must be serious to be covered.
· Reimbursement for outpatient hospital services is limited to $1,500 per recipient per Florida fiscal year.
· Labs have to be done at participating, non hospital based laboratories (like Quest).
· Physicians
o One doctor’s encounter, per specialty, per day (or Nurse Practitioner, not both on same day)
o One physician consultation per 365 days per physician, per specialty, per recpient when not hospitalized
o Such specialty consultations must be specifically authorized by the PCP within the month in which the consultation is to be scheduled.
· Surgery at participating hospitals must be medically necessary and previously approved.
· They cover emergencies.
So here is the problem. It is why my partner’s appointment and tests keep getting cancelled. When my partner was moved into this MediPass program, he had already been doing is normal post-transplant stuff IN A HOSPITAL BASED ENVIRONMENT. So his account was empty until July 1, 2013.
· Perioic post transplant appointments, labs and tests
o Transplant Surgeon every 2-4 months to check incisional hernia, acute rejection (biopsy at 1 year post transplant), and general post operative organ viability
o Hepatology every 6 months to evaluate Hepatitis C status and to plan for treatment
o Oncology every 4 months (Chest X-Ray and Abdominal MRI) to check for HCC recurrance
o Cardiology every 6 months (Transthorasic Echocardiogram) to check aortic stenosis and mitral valve problems, uncontrolled hypertension and occluded carotid arteries/mild.
o Nephrology once a year for chronic kidney disease, more if labs show a problem
o Gastroenterology once a year for chronic GI bleeding, more if a problem
And, he had a shoulder surgery in July that he waited 3 years to have done at Medicaid approved facility, where they fixed 4 different tears.
What to do?
· Jackson/UMiami Transplant Program wants the patients to have coordinated care by the Transplant Coordinator.
· MediPass/Florida Medicaid wants the patients to have all care coordinated at the PCP.
At our appointment with the PCP in August, she didn’t know what to do with my partner. We brought her a binder of 4 inches of lab reports, surgical reports, MRI discs. She wrote referrals back to all our doctors in Miami that she figured would cover appointments for a year. Should she spend half her day trying to figurer out how to care for my partner when the state pays her a capatated annual fee, regardless of how many times she sees him. He should be in a Traditional Medicaid category.
My partner applied twice to Medicaid in Tallahasee to have his Traditional Medicaid status reinstated and was denied. He got the second letter Friday.
His next approach will be to try to get something going from the top down. He wrote a letter to his US Senator from Florida who is likely to be re-elected.
They need to consider that only 1,000,000 people in the US are diagnosed with AIDS at this time. (ONLY?) Treatments for that disease are maturing and public health efforts to educate and test those at risk have been somewhat successful. Medications are working for those affected. That disease is on the list for special consideration.
3,000,000 Americans have Hep C. Three times as many as AIDS. And those aging patients who contracted Hep C are getting really sick. They contracted Hep C before it was identified, before its transmission was understood, before any real educational public health effort was launched (still no real effort but three times as many are infected!!!)
I wonder if my partner will be approved for Hep C treatment at all?
Once the election season is over and we know who will be seated in our area for the Florida House and Senate we will approach those folks also about broadening care needs for Hep C/Liver Disease patients. Specialty care is critical. Last time I checked, there is no Public Health Transplant Clinic in rural/suburban Florida. There are programs at Mayo in Jacksonville, Jackson I Miami, and smaller programs in Orlando and Tampa.
Meanwhile he will try to find quality local care for oncology and cardiology locally.
I continue to pray he can get post transplant care at Jackson/UMiami as an exception.
Earlier this month my partner was having bloody stools. The Transplant Coordnator set up 3 different colonoscopy/endoscopy apointments for my partner. All 3 were cancelled at the last minute. We tried to get the test done locally at a non hospital based program, but the Primary Care Physician had no appointment for 3 weeks and would not order the test without an appointment, so he was stuck.
His Transplant Coordinator had him admimtted to Jackson Transplant and he got his colonoscopy/endoscopy as an inpatient. They kept him 3 days, balanced his electrolytes and adjusted his uncontrolled hypertension while he was there.
Does my partner need to have an “emergency” every time he needs follow up care?
This has me not sleeping and worrying a lot.
I know times are tough. He is eligible for Medicare in 2 years, so I tell him not to blow those heart valves for 2 more year and he’ll be okay. And to hope that his Hep C can wait 2 more years for treatment.
I wonder what the’ll do about this upcoming surgery for the Incisional Hernia…send him home Friday morning and not do it after all?
Best,
Mama Lama