Micki Edelsohn's book "Mom with a Megaphone" is now available on Amazon

"Mom with a Megaphone" by Micki Edelsohn is now available on Amazon! 

See the review by Jill Escher from the National Council on Severe Autism:

The Homes that Micki Built: "Mom with a Megaphone" by Micki Edelsohn

A 2022 Appeals Court decision in a Washtenaw County case restored a favorable ruling in an administrative hearing to a DD adult.

FYI: (This case was decided in February 2022.) The guardian of a DD adult requested an administrative hearing to determine whether an increase in the adult's budget from CMH was necessary to allow him to achieve his goals written in an Individual Plan of Service. Ultimately, an administrative law judge in an appeals hearing sided with the adult with DD and his guardian. WCCMH appealed the decision to the Circuit Court. It turns out the law says that the administrative law decision is final and WCCMH had no right to appeal the decision. Here is a summary and explanation of the case from the Website of Disability Rights Michigan.

Wiesner: Making sure that when Michigan Medicaid recipients win administrative appeals, the win is final.

Case Status: Resolved

Case Filed: March 2019

Main Concern

Under federal Medicaid law, Medicaid recipients have the right to challenge decisions made by the state Medicaid agency and its contractual agents, like local community mental health organizations (CMHs).
These challenges come in the form of administrative appeals. The concern in this case was that the recipient won his administrative appeal, but the CMH then appealed the favorable hearing decision to a judicial court. [emphasis added]

Summary 

Kevin Wiesner receives services from Washtenaw County CMH (WCCMH). In 2019, Mr. Wiesner’s guardian told WCCMH the budget given for his services was not enough to do what those services were supposed to according to Mr. Wiesner’s individual plan of service (IPOS). Mr. Wiesner’s guardian asked for more money, which WCCMH denied. Mr. Wiesner appealed that decision, and an administrative law judge (ALJ) found Mr. Wiesner was right: his budget was indeed insufficient. 

WCCMH then appealed that decision to the Washtenaw County Circuit Court, even though, WCCMH is a contractual agent of the Michigan Department of Health and Human Services (MDHHS), and ALJ decisions are the final decisions of MDHHS. The Circuit Court reversed the ALJ’s decision. Mr. Wiesner then appealed from the Circuit Court to the Michigan Court of Appeals, which held that Medicaid agencies like WCCMH do not have the right to appeal ALJ decisions. This reinstated the ALJ’s decision.

Outcome

The Michigan Court of Appeals held in a published decision that Medicaid agencies (MDHHS and its contractual agents) do not have the right to appeal ALJ decisions, because ALJ decisions are the final decision of MDHHS. This reinstated the ALJ’s decision in favor of Mr. Wiesner.

Details

March 2019
Mr. Wiesner requests an increased budget from Washtenaw County CMH (WCCMH), to achieve the goals in his individual plan of service (IPOS). WCCMH denied the request. Mr. Wiesner would later request an internal appeal.

July 2019
After the internal appeal, WCCMH upholds its own denial of Mr. Wiesner’s requested budget increase.

November 2019
Mr. Wiesner appeals WCCMH’s internal appeal decision to the administrative court.

January 2020
The Administrative Law Judge rules in favor of Mr. Wiesner, finding that his budget is not enough to achieve the goals in his IPOS.

May 2020
WCCMH appeals the ALJ’s decision in favor of Mr. Wiesner to the Circuit Court.

November 2020
Circuit Court denies Mr. Wiesner’s arguments that WCCMH has no right to appeal the ALJ’s decision and reverses the ALJ’s decision.

March 2021
The Michigan Court of Appeals grants Mr. Wiesner leave (gives him permission) to appeal the Circuit Court’s order.

April 2021
Mr. Wiesner appeals the Circuit Court’s decision to the Michigan Court of Appeals.

February 2022
The Michigan Court of Appeals reverses the Circuit Court and reinstates the ALJ’s decision, holding that WCCMH has no right to appeal the ALJ’s decision.

The federal Public Health Emergency for COVID-19 expires on May 11, 2023. Here's what happens next...

The following is from a CMS  fact sheet: "CMS Waivers, Flexibilities, and the Transition Forward from the COVID-19 Public Health Emergency", Feb 27, 2023. It covers changes to CMS requirements for Medicare, Medicaid, private health insurance, and other entities that are in effect during the COVID pandemic and will be lifted on May 11, 2023. [CMS is the federal Centers for Medicare and Medicaid Services, the federal agency that regulates Medicare and Medicaid.]

Some of the federal requirements will change, but that does not mean COVID is going away anytime soon. Pay attention to COVID conditions in your state. Currently nationwide, 652 people a day are dying from COVID-19. For Michigan, all but two counties are considered to be "Low Risk" for the virus. One good source of information is the COVID Dashboard at BridgeMichigan.com.

These excerpts refer to Medicare and Medicaid requirements and waivers that gave flexibility in administering federally-funded programs. See the Fact sheet for a more complete picture of all that will be affected by the expiration of the Public Health Emergency. (Most adults with developmental disabilities qualify for Medicaid based on their low income and disability. Many adults also qualify for Medicare when a parent retires or dies or when the disabled adult retires from employment.)

Excerpts from the FACT SHEET:

"The emergency declarations, legislative actions by Congress, and regulatory actions across government, including by the Centers for Medicare & Medicaid Services (CMS), allowed for changes to many aspects of health care delivery during the COVID-19 PHE. Health care providers received maximum flexibility to streamline delivery and allow access to care during the PHE [Public Health Emergency]. While some of these changes will be permanent or extended due to Congressional action, some waivers and flexibilities will expire, as they were intended to respond to the rapidly evolving pandemic, not to permanently replace standing rules."

"...For more information on what changes and does not change across the Department, visit https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html "

Medicare

"Vaccines: People with Medicare coverage will continue to have access to COVID-19 vaccinations without cost sharing after the end of the PHE.

"Testing: Additionally, people with traditional Medicare can continue to receive COVID-19 PCR and antigen tests with no cost sharing when the test is ordered by a physician [or other healthcare professional]..

"Treatments: There is no change in Medicare coverage of treatments for those exposed to COVID-19 once the PHE ends, and in cases where cost sharing and deductibles apply now, they will continue to apply. Generally, the end of the COVID-19 PHE does not change access to oral antivirals, such as Paxlovid and Lagevrio."

Medicaid and CHIP(Children's Health Insurance)

"Vaccines, Testing, and Treatment: As a result of the American Rescue Plan Act of 2021 (ARPA), states must provide Medicaid and CHIP coverage without cost sharing for COVID-19 vaccinations, testing, and treatments through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 PHE. If the COVID-19 PHE ends as expected on May 11, 2023, this coverage requirement will end on September 30, 2024.

"After that date, many Medicaid and CHIP enrollees will continue to have coverage for COVID-19 vaccinations. After the ARPA coverage requirements expire, Medicaid and CHIP coverage of COVID-19 treatments and testing may vary by state.

"Additionally, 18 states and U.S. territories have opted to provide Medicaid coverage to uninsured individuals for COVID-19 vaccinations, testing, and treatment. Under federal law, Medicaid coverage of COVID-19 vaccinations, testing, and treatment for this group will end when the PHE ends."

Private Health Insurance [See the Fact Sheet for details]

Access to Telehealth Services

...“'Telehealth' includes services provided through telecommunications systems (for example, computers and phones) and allows health care providers to give care to patients remotely in place of an in-person office visit."

"The Consolidated Appropriations Act, 2023, extended many telehealth flexibilities through December 31, 2024, such as:
    •    People with Medicare can access telehealth services in any geographic area in the United States, rather than only those in rural areas.
    •    People with Medicare can stay in their homes for telehealth visits that Medicare pays for rather than traveling to a health care facility.
    •    Certain telehealth visits can be delivered audio-only (such as a telephone) if someone is unable to use both audio and video, such as a smartphone or computer."

Medicaid, CHIP, and Telehealth
 
"For Medicaid and CHIP, telehealth flexibilities are not tied to the end of the PHE and have been offered by many state Medicaid programs long before the pandemic. Coverage will ultimately vary by state. CMS encourages states to continue to cover Medicaid and CHIP services when they are delivered via telehealth."

COVID-19 Waivers and Administrative Flexibilities: How Health Care Providers and Suppliers are Affected [See the Fact Sheet] This includes Hospital at Home, Nurse Aide Training for Nursing Homes, Virtual Supervision, Scope of Practice, and Health and Safety Requirements, 

Medicaid Continuous Enrollment Condition

"The continuous enrollment condition for individuals enrolled in Medicaid is no longer linked to the end of the PHE. Under the Families First Coronavirus Response Act, states claiming a temporary 6.2 percentage point increase in the Federal Medical Assistance Percentage (FMAP) have been unable to terminate enrollment for most individuals enrolled in Medicaid as of March 18, 2020, as a condition of receiving the temporary FMAP increase." [FMAP means the Federal Medical Assistance Percentages (FMAPs) that are used in determining the amount of Federal matching funds for State expenditures for assistance payments.]

"As part of the Consolidated Appropriations Act, 2023, the continuous enrollment condition will end on March 31, 2023. The temporary FMAP increase will be gradually reduced and phased down beginning April 1, 2023 (and will end on December 31, 2023). For more information, visit Medicaid.gov/unwinding."

From the Kaiser Family Foundation (KFF)

"At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA), which included a requirement that Medicaid programs keep people continuously enrolled through the end of the month in which the COVID-19 public health emergency (PHE) ends, in exchange for enhanced federal funding.Feb 22, 2023"

 

See also, "10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision" by Jennifer Tolbert and Meghana Ammula, Feb 22, 2023