Memisovski v Maram Powerpoint

8/10/2019 Memisovski v Maram Powerpoint

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A Case Study


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The Evolution of MedicaidMedicaid became law in 1965 through Title XIX of theSocial Security Act (42 U.S.C.A. 1396)It grew out of and replaced two earlier programs of Federalgrants to States that provided medical care to welfarerecipients and the aged. Although funded by both the federal and stategovernments, each State determines who is eligible, thescope of services, the rate of payment for services, andadministers its own program. While State participation is voluntary should it choose to participate the Statesprovisions must comply with the Medicaid Act.


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Who Qualifies for Medicaid?Medicaid eligibility is not determined solely byeconomic status. . Medicaid covers only certaingroups of low-income persons who fall into specialcategories.Categories included in Federal Medicaid coverage

Children

Pregnant womenDisabled individualsElderlyBlind


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An Ineffective State Planhttp://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/

Thoughts about the video? Who do you think is to blame for this situation?Is it the responsibility of doctors and medicalorganizations to donate free care?

How do you think legal aid organizations can help?Other people not covered under Medicaid

Men under 65 Women unless pregnant
http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/http://www.mefeedia.com/entry/video-girl-loses-eye-medicaid-denies-claim/10855074/


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State Plans Must Include: A state plan must include a comprehensive statementdescribing the nature and scope of the StatesProgram to the secretary of Health and HumanServices for approval At issue in the case were two provisions:

A state plan must ensure equal access to health care

providers A state plan must provide access to early and periodicscreening, diagnostic, and treatment services(hereinafter EPSDT)


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Equal Access Provision42 U.S.C. 1396a(a)(30)(A) ensures all Medicaidrecipients receive pediatric care and services to theextent that such care and services are available to thegeneral populationIn Memisovski the plaintiffs alleged that statepayments to Medicaid providers were so low that equal

access did not exist


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Facts About Equal Access at the

Time of MemisovskiMedicaid paid only 55% of the rate that Medicare paid forthe same service and Medicaid rates are significantly lowerthan private insurance reimbursementMedicaid rates did not even cover a physicians overheadcost in Cook County Virtually no pediatric dentists in Cook Country acceptedMedicaid. A dentists practice would fail financially if allMedicaid patients were acceptedChildren on Medicaid rarely got vision and hearing screensfrom physicians who provide EPSDT services and weremore likely to see a physician that was not board certified


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EPSDT Provisions (42 U.S.C.

1396d(r)(1)(B)The EPSDT provisions are located throughout theMedicaid Act and ensure amongst other things:

Timely screenings for medical, vision, and developmentalconditionsThe goal is preventative in natureScreening services must include:

comprehensive health and developmental history including both

physical and mental assessment, comprehensive unclothed physicalexam, appropriate immunization, laboratory tests, lead toxicityscreening, health education, vision services, dental services, hearingservices, and other necessary health care services to correctconditions discovered by the screening services.


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Facts About EPSDT Services Under the EPSDT program in Illinois, a child shouldreceive seven appointments by age one, four more inthe second year of life, and continue to receivescreenings, as the child gets older.45.3% of children in Cook County had no well-child visits in the first year of life.

Significant failure was found across all categories ofthe Illinois EPSDT plan.


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Memisovski Plaintiffs600,000 Cook County MinorsExamples of the plaintiffs experience:

Emergency Room physicians would need to call in favors to

find physicians to provide follow-up care to Medicaidrecipients who presented in the Emergency Room andrequired further treatment. These Emergency Roomphysicians reached a point where they could only call in somany favors leaving Medicaid recipients without proper care

Medicaid would reimburse costs for single hernia surgeries. AMedicaid recipient suffering from a double hernia was forcedto undergo two separate surgeries. This allowed the physicianto be compensated by Medicaid for two single herniasurgeries because Medicaid would not cover a double herniasurgery.


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Video: Illinois Programs Impacted

by Financial Woes57 Beds Documentaryhttp://www.youtube.com/watch?v=AVIVWn7SBHY

Charities & fundraisers are often necessary to keepprograms runningIllinois Representatives have little faith in the systemQuestions

Do you think the Illinois population is aware of howMedicaid is run?Do you think the state or federal government needs totake more control?
http://www.youtube.com/watch?v=AVIVWn7SBHYhttp://www.youtube.com/watch?v=AVIVWn7SBHY


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Timeline of the CaseIn 1992 the Legal Assistance Foundation (LAF) filessuit

Initially there were two classesAll children (persons under the age of 18) in Cook County,Illinois, who, on or after July 1, 1990, have been, are, or will beeligible for the Medical Assistance Program (Medicaid)

established under Title XIX of the Social Security Act.Women in Cook County on Medicaid who have been, are, or will be pregnant. (Class voluntarily dismissed on May 29,2003)

From 1992 to July 2, 1999 the case was stayedThe case moves from LAF to other organizations

Shriver Center-National Institute on Poverty LawChicago-Kent Law School ClinicsHealth and Disability Advocates

Defendants newly implemented programs failed


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Timeline cont.Motion to dismiss 2000198311th amendment

DiscoveryTrial

Changes in judge and attorneys1983

ArgumentsTestimonyHolding

Consent Decree


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Motion to Dismiss11th Amendment

Bars suits by private parties against a state

Ex Parte Young Doctrine 1983Blessing v. Freestone

3 Part Test

Judge LefkowDenied motion October 17, 2001


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Key Players at the Trial PhaseThe AttorneysDefendants maintain same counsel (Attorney Generals)Plaintiffs forge bond between public interest organizations and privatecounsel

Private Counsel (Goldberg Kohn)Mr. Fredrick Cohen & Mr. David Chizewer Pro-bono case leads toreimbursement for attorneys fees!Firm receives national publicity & record setting case

U.S. ex rel. Tyson v. Amerigroup Illinois, Inc.488 F.Supp.2d 719 (N.D.Ill. 2007)

The Judge (Judge Lefkow)Thoughts on the assigned newspaper article?!Consent Decree rather than appealing the Judges decision


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Judgment on the Pleadings1983 changesGonzaga University v. Doe

Part 1 of the Blessing testspeak with a clear voice unambiguous intent

rights creating language Equal Access Provision

Defense ArgumentsNot intended beneficiariesNo rights creating language

Aggregate focus not individual rights

42 U.S.C. 1320a-2 and Suter

EPSDT Provisions


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Trial TestimonyTestimonyFindings of fact on Equal Access provision

The costs of medical practice in Cook County are 20% more expensive than in downstate Illinois, yetMedicaid reimbursement rates are the same.Medicaid paid only 55% of the rate that Medicare paid for the same service and Medicaid rates aresignificantly lower than private insurance reimbursement.Medicaid rates do not even cover a physicians overhead cost in Cook County. Virtually no pediatric dentists in Cook Country accept Medicaid. A dentists practice would fail financially ifall Medicaid patients were accepted.Children on Medicaid rarely get vision and hearing screens from physicians who provide EPSDT services andare more likely to see a physician that is not board certified.

Findings of fact on EPSDT provisions EPSDT screenings involve comprehensive health and developmental history, comprehensive unclothedphysical exams, immunizations, tests, lead screenings, health education, screenings for vision, dental, andhearing45.3% of children in Cook County had no well-child visits in the first year of life.The plaintiffs enlisted another expert to testify regarding the dissemination of information regarding theMedicaid and Healthy Kids program. The expert testified that due to the difficulty and length of the materiala significant portion of the population would be unable to understand them


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Plaintiffs ArgumentsEqual Access Provision Arguments

The law requires that Medicaid reimbursement rates paid to health careproviders be sufficient to provide Medicaid recipients access to healthcare equal to that of the generally insured population;The arbitrary and capricious manner in which the defendants setreimbursement rates has resulted in rates that are far too low to result inequal access to care;The plaintiffs endure obstacles to finding care not faced by privately

insured patients.EPSDT Provisions

Effective Efforts to informServices

Periodicity Schedule


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HoldingThe Court found that the defendants were in violationof both the equal access provision and EPSDTprovision of the Medicaid Act and set the case forstatus to discuss an appropriate remedy.


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Consent Decree June 27, 2005 Notice of Hearing to Class MembersNovember 18, 2005

Parties work together to create a remedial planDefendants have help from outside counselGoldberg Kohn continues to work

The 61 page consent decree is finally entered

http://www.hdadvocates.org/_files/HDAFiles/Press%20Room%20Materials/PR%20Memisovski%20Consent%20Decree.pdf November 29, 2007

Memisovski v. Maram 2007 WL 4232716Plaintiff s win at a hearing regarding the method to be used tocreate a study on access to specialist services by class member andnon-class member children

Mail survey v. audit surveyPresent Day

Consent decree continues to be implemented
http://www.hdadvocates.org/_files/HDAFiles/Press%20Room%20Materials/PR%20Memisovski%20Consent%20Decree.pdfhttp://www.hdadvocates.org/_files/HDAFiles/Press%20Room%20Materials/PR%20Memisovski%20Consent%20Decree.pdfhttp://www.hdadvocates.org/_files/HDAFiles/Press%20Room%20Materials/PR%20Memisovski%20Consent%20Decree.pdfhttp://www.hdadvocates.org/_files/HDAFiles/Press%20Room%20Materials/PR%20Memisovski%20Consent%20Decree.pdf


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Changes to the Illinois Medicaid

System January 2005, Governor Blagojevich drasticallyreformed Medicaid developing the Illinois All KidsProgram.Nations first universal coverage program for children.

All Kids is Illinois program for children who needcomprehensive, affordable health insurance, regardlessof family income, immigration status or healthcondition.

Builds off of Illinois state Medicaid and StateChildrens Health Insurance Program (SCHIP) but isfunded exclusively with state funds.


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Questions

Does anyone have questions thus far?Medicaid is a hot topic given the upcomingpresidential race, lets take a closer look at thecandidates views towards Medicaid

Senator McCainSenator Obama


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Current Issues in PoliticsSenator McCain:McCain favors the Health Care Choice Act which would allowcitizens to purchase health insurance nationwide instead of

limiting them to in-state companies, and to buy insurance throughany organization or association they choose as well as through theiremployers or buying direct from an insurance company. ( McCain isRight on Interstate Health Insurance, Wall St. Journal, October 1,2008 )

At the heart of his plan are tax credits - $2,500 for individuals and$5,000 for families who do not subscribe to or do not have access tohealth care through their employer. ( McCains Health CareProposal, BusinessWeek.com, April 29, 2008)


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Against publicly funded health care, universal healthcare, or health coverage mandates.In an October 2007 statement, McCain said: "In healthcare, we believe in enhancing the freedom ofindividuals to receive necessary and desired care. We

do not believe in coercion and the use of state power tomandate care, coverage or costs. ( McCains Health CareProposal WashingtonPost.com, Oct. 10, 2007)


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In recent news:Senator McCain would pay for his health plan withmajor reductions to Medicare and Medicaid,

a top aide said, in a move that independent analysts estimatecould result in cuts of $1.3 trillion over 10 years to the

government programs. ( McCain Plans to Cut Medicaid and Medicare The Wall Street Journal, 2008)The nonpartisan Tax Policy Center, a Washington think tank -assessed that the plan would allow as many as five millionmore people to have insurance


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Senator Obama

Universal Heath Care"The time has come for universal health care in America [...] Iam absolutely determined that by the end of the first term ofthe next president, we should have universal health care inthis country." (Pickler, Nedra, Obama Calls for UniversalHealth Care , Associated Press, January 25, 2007)Obama cites cost as the reason so many Americans are without health insurance.Obama's health care plan includes implementing guaranteedeligibility for affordable health care for all Americans, paid forby insurance reform, reducing costs, removing patentprotection for pharmaceuticals, and required employercontributions.He would provide for mandatory health care insurance forchildren.


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Video: A Tribute to Medicaidhttp://www.youtube.com/watch?v=tq-hXWhk6dI An individual shares her experiences with Medicaid via song and dance
http://www.youtube.com/watch?v=tq-hXWhk6dIhttp://www.youtube.com/watch?v=tq-hXWhk6dIhttp://www.youtube.com/watch?v=tq-hXWhk6dIhttp://www.youtube.com/watch?v=tq-hXWhk6dI

Memisovski v Maram Powerpoint

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