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Medical
Issues Affecting Special Needs Children-Key Issues Ø
Mandatory
enrollment in managed care-Aid to Families with Dependent Children and
Temporary Assistance for Needy Families enrolled and next were blind,
aged, and disabled populations. Voluntary
enrollment vs. autoassignment, exemptions, being assigned correct PCP are
concerns. Ø
“Dual
eligibles”-eligible for both Medicaid and Medicare. Ø
Access
to pediatric specialists. Ø
Private
insurance concerns: in-network/out-of-network
deductibles and out-of-pocket expenses; inconsistent payments;
charge-backs for claims “paid in error”; “medical vs.
educational”; families unaware of extended school year program for
therapy; denials as not “medically necessary”; cover rehabilitative
therapies for adults, not habilitative services for children; lifetime
caps used up or changed upon diagnosis; families “dropped” by
insurers; birth defects denied as “pre-existing”
conditions; “coordination” of benefits-if primary pays same as
secondary, secondary pays nothing. Ø
Educational
issues: medical evaluation
eliminated for classification, “neurologically impaired” redefined,
homebound instruction program revised. Ø
Supplemental
Security Income regulations revised:
need “marked and severe” conditions, discontinued Individual
Functional Assessment, 80% who lose SSI may still keep Medicaid,
Association for Children in NJ provided free legal representation,
N.Y. Times article cited NJ one of states with large restoration of
benefits, NJ also 1 of 2 states with an SSI Alliance. Ø
Children’s
health insurance programs, Kidcare: expansion
of Medicaid; uninsured previous 12 months, legal immigrants still
eligible, enrollment goal is low so doing outreach. Ø
Managed
care legislation: The Health
Care Quality Act-insurers must disclose PT, OT, speech coverage; parity
for mental health coverage (N.J. Alliance for the Mentally Ill also
working on this); may not retroactively deny claims/charge back.
Key legislators-Sen. Torricelli, Sen. Sinagra, Assemblywoman
Vandervalk, Assemblymen Talarico and Corodemus. Ø If families or professional have questions regarding children with special health care needs, Family Voices can help.
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