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A Letter to Health and Human Services and Texas Legislators

Dear Health and Human Services Commission (HHSC) Director and Texas Legislators:

I am writing to you today as a parent, therapy provider, and concerned citizen regarding the significant delays Texas Medicaid is currently experiencing with authorizations which are drastically affecting continuity of care and quality of life for my son and thousands of Texas children. These delays seem to be a direct result of recent legislation passed to decrease funding to the Texas Medicaid program by approximately $350 million (Rider 50). While the proposed budget cut is currently on hold due to a court injunction, it would appear HHSC has implemented these cuts in the form of delaying authorizations in effort to save the program money.

As a provider, here is just one such example. I received an authorization September 15, 2016 at 7:15 pm via fax. Our office submitted this authorization request on August 1, 2016 – 46 days ago. This letter is dated September 1, 2016 and the authorization period begins on August 15, 2016. The Texas Medicaid Provider manual states that services will not be compensated for without an authorization and authorizations will not be backdated, so therefore, we as providers, must tell our therapists that they cannot see their patients until authorization is received or we risk not receiving payment for services rendered. In this case, our therapist has not seen their patient since the evaluation was performed on August 1st. Now, here we are 46 days later and we find out that 15 days ago our authorization was approved and backdated an additional 15 days, so our patient has missed a month of therapy because we were not notified in a timely manner. Furthermore, our request was for two visits per week and the reviewer denied our request suggesting our patient only required one visit a week due to “slow progress toward therapy goals. “ This is only one example of many we have personally experienced and the countless more we know other patients and providers to be currently experiencing across the state. On average, our authorization requests are taking 4-6 weeks to be approved, if no additional information is requested. If Texas Medicaid & Healthcare Partnership (TMHP)  requests additional information, the delay is an additional 2-3 weeks, at minimum. Per the TMHP manual, we cannot submit authorization requests more than 30-days prior to the expiration of a current authorization rendering us unable to be proactive and submit requests 4-6 weeks in advance. As a result, with the current timeline of approval our patients are experiencing 2-3 week lapses in therapy service, and sometimes greater.

These delays are detrimental to the health and well being of our patients. One month without therapy can cause significant regression for chronically ill and long-term disabled children. To add insult to injury, our patients are experiencing regression and loss of skills due to authorization delays and when our request is reduced to once a week visits instead of twice a week, our patients do not have adequate service to reach their prior level of skill nor continue to make significant progress toward goals. Progress is slow because our therapists have to take several steps backward to get our patients back to where they were before there was a lapse in treatment. And then attempt to make progress toward the goals previously set.

The authorization delays directly coincide with the time period in which the court issued an injunction to delay implementation of Rider 50, which would reduce payment for therapy providers. Thousands of children across the state are experiencing lapses of 3 weeks or greater, which, in turn, is undoubtedly saving the state a great deal of money. This seemingly underhanded attempt to implement the budget cut despite court rulings is gross negligence and directly impacting the lives of our children. For many children, therapy is required to maintain current level of function, to decrease the chance of contractures or serious injury, to ensure safety in the environment, to improve and strengthen fine and gross motor skills, to teach speech, to correct speech deficits, to ensure safe feeding, to improve quality of life by teaching skills that will allow children to interact with their peers, and for so many other reasons. Therapy is a cornerstone of ensuring proper development in children.

Additionally, providers have tried to address these concerns with TMHP reviewers and we are told that authorizations are going to nurse review and there is no time period for which they must be approved. Meanwhile, parents are calling TMHP and the Medicaid Ombudsman’s office and being told that authorizations should be approved within 3 business days. As a result, our patients assume it is the providers delaying the authorization and we are losing the trust and rapport we have worked hard to earn from our patients.

The lives of our state’s most vulnerable citizens seem to constantly hang in the balance while legislators and state departments toy with policies looking to save money all while harming the lives of children. It is clear that the powers that be do not understand the needs of special needs community nor do they know how to meet those needs. As a result, children across the state are currently without the necessary services that would improve their quality of life. This issue needs to be rectified immediately. As it stands, the state is currently profiting off of the steady decline in health and absence of service for our children, which is simply abhorrent, to say the least.

I hope your respective offices will look in to the matter and ensure corrective action will be taken. My son has a life-long disability and depends on therapy services to provide him his best chance at success in life. The issues I continue to see with Texas Medicaid provide me with little hope for his future. I know that one day soon, his service will be denied, as it has been for several of our chronic patients, because what we see as leaps of progress, you deem to be “too little” progress. While Texas is historically a pro-life state, the state places little value on the lives of the disabled, which is evident when legislation passes that can directly harm their lives. It is unfortunate when families like ours rely on the Texas Medicaid program, even as a secondary insurance (as we do), because without it we simply could not afford the staggering costs associated with caring for a disabled family member, only to have that crucial support ripped away due to systemic downfalls and budget cuts.

As you prepare for the next legislative session, it is my hope you will have greater consideration for the lives of your most vulnerable citizens. They are your sons, daughters, nieces, nephews, grandchildren, and they desperately need you to speak up for them in these matters because they deserve the right to a full life. They deserve access to quality healthcare, to programs that enrich their lives, to services that will enable them to become successful tax-paying citizens. We, the families, the providers, the taxpayers, hope for a resolution – sooner rather than later.

Sincerely and with hope,

A Texas Mother looking out for her son and the lives of all Texas children

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Filed under Kids and Family, Special Needs Child

The Swingset That Almost Wasn’t

Earlier this year, I learned that Braxton became eligible for programs provided by the Department of Assistive and Rehabilitative Services (DARS) Division of Blind Services (DBS). One of the DBS’ main goals is to help individuals get involved in their community and to help them do the same things as their peers. As part of this mission, DARS-DBS will cover the cost of camps, alternative therapy (music therapy, hippotherapy, aquatic therapy, etc), learning toys, therapeutic equipment, and much more.

At a recent meeting with our case manager, we mentioned looking into buying a trampoline or playground set for our backyard. A few days later I received a call that there was money in the budget for DARS-DBS to purchase a playground set for Braxton. I was shocked and elated! Braxton loves going to the playground to swing, and now he would be able to do it anytime he wanted. Not to mention how beneficial it would be for our in-home therapists to implement in their programs. We were thrilled and made plans to meet our case manager at the local Walmart to make the purchase.

The elation was short lived.

We arrived to Walmart and ran into issues making the purchase. The cashier did not know how to process the transaction using the DARS-DBS state credit account, so he called a customer service rep. The rep (who was in no hurry at all to help) finally arrived and completed the transaction. As we waited for help to load the swing set into our truck, the rep frantically came back and told us there was a problem. He said that this type of transaction was not allowed and we could not take the set with us. Our case manager tried to explain the process to the young man and let him know that the program makes purchases like this throughout Texas and have never had an issue. As the rep repeatedly huffed, puffed, and rolled his eyes he continued to insist that this wasn’t allowed per his manager. He was reluctant to help and refused to call the 1-800 number on the voucher for further instructions. When we asked to speak to the manager, he made some calls, and then simply turned around and said “Yea, my manager said we can’t do this.” After demanding to speak face-to-face to a manger, one finally arrived. We explained the situation again, pointed them to a 1-800 number on the voucher and asked that they please call that number to verify the purchase rules and how to go about processing this for us. After some time, the manager and customer service rep returned to say that hotline was closed so they could not get through to anyone who could verify this type of purchase. This all happened over the course of about 2 hours.

At this point, the manager was at least somewhat apologetic about the situation, but adamant that this type of purchase was not allowed at their store. He even brought out the Asset Protection Manager who tried to tell us keying in the account number was absolutely against company policy. He stated that he would attempt to call the number the next morning to try and get it resolved. Our case manager made plans with us to meet again the next day.

The next day arrived and our case manager called before we all headed up to the store again. The manager said he had not yet called, but would call ‘within the hour.’ Over an hour passed with no word, so our case manager called him and he said that he had been trying “all morning” but the line would just ring and ring with no answer. The case manager called the number herself and got right through. She obtained some further information about the Walmart Corporate office to give to the store manager to hopefully resolve everything. After several phone calls and several hours, everything was finally resolved and the manager gave the okay for us to make the purchase. We returned to the store and again the cashier did not know what to do and called a customer service rep. We told them which manager we spoke to and asked that they please call him to verify that the purchase could be made. Finally, the purchase was completed and we got the swing set home.

The entire situation was so poorly handled by nearly every employee involved. Having worked in retail, I can certainly understand the frustration something like this brings, but I do not at all understand the pure lack of empathy and poor attitude by the entire staff. Not one person was willing to go above and beyond “what they’re paid for” to help a customer.

There are several things that could have been done to help us out from the beginning. For one, the customer service rep should have brought the manager over immediately instead of making us feel like a burden for making him do his job. Secondly, he should have called the hotline when we arrived and the office would have been open. Instead, his reluctance dragged the time on which made us miss the people who could have helped everything. Thirdly, when our case manager brought it to their attention that she has personally made these purchases at nearby Walmart locations, the manager could have offered to call one of the other stores to speak to a manager who has done this before, but that never crossed his mind. Lastly, once the manager finally learned that this type of purchase was allowed, he should have personally gone over to the garden center and/or Customer service to let them know we would be returning to make this purchase. None of this was done. In fact, absolutely nothing was done or said to help rectify the situation.

The really unfortunate thing is that we are not the only family in this area served by DARS-DBS, and now because of this experience it would be difficult for our case manager to take another family there only to be turned away. If the manager did not prepare his staff for our arrival the day he learned of this program, it is highly unlikely there will be any storewide training and every family who enters will be made to face this kind of treatment, which is absolutely unacceptable. They have lost business simply because of their unwillingness to learn, adapt, and go above and beyond their pay grade.

Braxton on his swing set

We finally put that swing set together this week. The pure and simple joy on my son’s face, made the hassle worthwhile, but it reminded me of the fight we face all too often with the “gatekeepers.” The gatekeepers who keep us from making appointments in a timely manner, the gatekeepers who keep us from services that could greatly help my son’s quality of life, the gatekeepers who show no emotion and no empathy for the very people they are supposed to help. Everything in our life has been a struggle. Getting a swing set to help my son be like other 4 year olds frolicking in their backyard wasn’t supposed to be so difficult. There was a time I didn’t know if he would ever be able to swing or slide down a slide at the playground, much less one in our backyard. Thanks to DARS-DBS he can now have that experience just like other kids his age.

 

Swingset Therapy

The set is also now a huge part of our therapy plan. Our Physical Therapist has already had Braxton outside working with him to climb the stairs so he can slide down all on his own. I stood by and watched as they worked together. I saw Braxton’s foot go up to the next rung unprompted and thought of all the hard work it took for him to gain that skill. For now, he needs help, but one day (soon) he will be able to maneuver the playscape with little to no help. What a shame it would have been had we allowed yet another gatekeeper to keep us from having this experience.

If this makes it back to our local Walmart, I want you to look at the joy on this little boy’s face, and I want you to know that YOU helped put that smile on his face. Yes, you made it quite difficult for us, but at the end of the day it doesn’t matter whether you apologized or admitted you were wrong (although that would be nice), what matters is this sweet face and the fact that YOU have the potential to help other kids like him with much less hassle. I hope that you learned something from having us in your store. I hope that you share what you learned with others so that this wonderful state agency can continue serving children in our area. All of our children deserve a chance to just be children. Not children with disabilities, just children. Children who want to play and be free and be loved. Please don’t take that away from our sons and daughters.

 

Braxton on the slide

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Filed under Life, Special Needs Child