THE DANDELION CONNECTION
Ellicott Square Building., 295 Main Street Room 495, Buffalo, New York 14203
Volume 5 Issue 5
(716) 847-0655 ext. 226 September/October 1997
Copyright 1997, Neighborhood Legal Services, Inc.
MEDICAID AND
MANAGED CARE (HMOS)
HMOs ARE COMING TO ERIE COUNTY
!!!
WHAT IS
MANAGED CARE?
New York State will soon require most Medicaid recipients in 31 upstate counties, including Erie and Niagara Counties, to receive health care through a managed care provider. Erie County is expected to have mandatory HMOs within the next few months for TANF families. Individuals should be prepared at their next recertification interview to hear about HMOs. Community Blue, Independent Health, Plus Med, and Better Health Plan are local HMOs. Managed care providers are commonly known as Health Maintenance Organizations or "HMOs". Doctors and health centers that take patients from your HMO are called "network providers." All other doctors who are not in the HMO are considered "out-of-network" providers.
WHO WILL MY DOCTOR BE?
In an HMO you must select a primary care physician from those available in the plan or else you will be assigned a physician. The HMO must provide you with a list of doctors you can choose from. Your primary care physician coordinates your health care and makes any referrals you need &emdash; for example, to see a specialist. Except in an emergency, you almost always must see your primary care physician before going to any other doctor.
IS MANAGED CARE MANDATORY
FOR EVERYONE?
There are some exceptions to mandatory
managed care:
In these and all other cases, make sure you have prior approval before making out-of-network arrangements. Problems happen most frequently because clients do not get prior approval. Be careful &emdash; you could be responsible for payment if you don't get a referral from your primary physician.
WHAT IF THE HMO DOESN'T
PROVIDE A SERVICE I NEED?
If your HMO does not provide a medical service that you need, you have the right to receive Medicaid-covered health services from out-of-network providers. However, your primary care physician must first give you an approved referral or else you may be responsible for payment.
WHAT IF I HAVE AN EMERGENCY?
All managed care plans must provide for emergency services for medical necessities. Medical necessities are conditions that the average person would expect to result in serious damage to one's health if not treated immediately. You do not have to get approval from your primary care physician for emergency care, but remember that HMOs are not required to pay for emergency services that are not medical necessities. HMOs may try to claim you did not have an emergency &emdash; be sure your emergency is a medical necessity.
WHAT IF I HAVE A PROBLEM WITH MY MANAGED CARE PROVIDER?
All HMOs are required to establish grievance procedures for any complaints or disputes you have, and utilization reviews for any questions about the medical necessity of services or procedures you or your doctor request.
HOW DOES THE
GRIEVANCE PROCEDURE WORK?
Your HMO plan must explain in the member
handbook how to file a grievance for any complaints or disputes you have with the HMO. In
many cases you can file a grievance over the phone through a toll-free number. Your
grievance must be decided within:
When you call or send in your grievance, make sure you ask what, if any, additional information is needed to make a decision so that your grievance is not unnecessarily delayed.
You will receive a grievance decision in the mail explaining the reason for the decision. If you disagree with the grievance decision you can appeal within 60 days of the date you received the unfavorable decision. Appeals must be in writing and must be resolved within 30 business days or within 2 business days when a delay would significantly increase the risk to your health.
HOW DOES THE UTILIZATION REVIEW PROCEDURE WORK?
You can ask for a Utilization Review (UR) either before, during or after your course of treatment any time your HMO refuses to provide a service because it is not medically necessary.
Example: Monica discovered a lump in her breast. Her doctors performed a mastectomy, but her managed care provider refused to pay for any cosmetic reconstruction because such reconstructive surgery was not "medically necessary." Monica and her doctor can request that the managed care provider conduct a utilization review to determine whether or not they should pay the bill for her reconstructive surgery.
You will receive a UR decision after the
receipt of all necessary information within:
An "adverse determination", (meaning the request is not medically necessary), must be in writing and contain the clinical reason for the decision and the procedures for filing an appeal. Appeals of a UR determination must be made within 45 days of a UR decision, and you must receive a decision on your appeal within 60 days of filing.
DO I HAVE ANY OPTIONS BESIDES THE GRIEVANCE & UR PROCEDURES?
While you are using the grievance or UR and appeal procedures set up by your HMO, in most cases you can also apply for a Fair Hearing and continue to receive aid. You do not have to use your managed care plan's procedures first before seeking a remedy through a Fair Hearing.
ALERT: Work Requirements are in Effect
TANF (Temporary Assistance to Needy Families) has work requirements which are currently in effect. Presently, each head of household with a child age 3 or over will be responsible for some type of work activity for at least 20 hours per week. This may include, but is not limited to on-the-job training, community service programs (CWEP/HIRE), vocational educational training (not to exceed 12 months) and part-time employment of at least 20 hours per week (i.e, obtaining a job of your choice). Please note that there may be upcoming welfare reform legislation which could change the above requirements.
CHILD CARE AND EDUCATION
Please see your Employment Counselor before entering college or any type of training program. The employment counselor is NOT your caseworker. The Employment Counselor works for the Department of Social Services, but only handles issues involving your employable/educational skills. Unfortunately, there are many individuals who have walked away with the misunderstanding that they could enter a college or vocational program simply because they mentioned it to a caseworker. Please do not make that mistake.
If you have NOT had an assessment done by an employment counselor, and the program you have chosen is NOT approved by the Department of Social Services, you may be held responsible for payment of your own day-care costs while you are attending school/training. In addition, you may also have to complete at least 20 hours of work in addition to your school/training (as noted above). To avoid any problems, be sure to see your Employment Counselor first. You can reach the Employment Complex by calling 858-8619 or by visiting the office located at 478 Main Street in Room 210.
If you have questions or
concerns regarding any of the above information, please call
Project Dandelion at 847-0650 ext. 217.
RENT-TO-OWN
Although buying in a rent-to-own transaction sounds like a simple solution when you are short of cash, rent-to-own can be expensive. The rental charge can be three or four times what it would cost if you paid cash or financed the purchase at the highest interest rate typically charged in installment sales.
Before signing a rent-to-own contract, ask
yourself the following questions:
If you decide that rent-to-own is the best
choice for you, here are some questions you should ask before you sign on the dotted line.
Comparison shop among various rent-to-own merchants. Contact your local or state consumer protection agency to find out if there are any complaints on record against the business. Check for any specific state laws. Read the contract carefully and make sure you understand all the terms and get all promises in writing. In Erie County, call the Erie County Consumer Protection Agency at 858-8709 for help with problems.
Remember, know what you are paying. Compare the cash price plus finance charges in an installment plan with the total cost of a rent-to-own transaction.
Long-term rent-to-own contracts cost so much more than installment plans that you could rent an item, make a number of payments, return the item, buy it on an installment plan and still come out ahead.
Information provided by the
U.S. Office of Consumer Affairs.
Where's Maggie?
Maggie O'Malley of Project Dandelion is still at the front door. However, she is now located in the rear of the Rath Building near the Emergency Housing Unit of the Erie County Department of Social Services. Please ask for Maggie at Window 9 or 10, and she will be glad to assist you.
DON'T SHAKE THE BABY!
Here's What to do Instead
When your baby cries and cries, it is easy to get very frustrated. You may be tempted to shake your baby to try to get him or her to stop crying. Please don't shake the baby!
Babies have heavy heads, weak
neck muscles, and thin skulls - shaking them can kill them. Jacy Showers, of the
Ohio Research Institute on Child Abuse Prevention, has some suggestions for what to do
when your baby cries often, and will not stop:
Once your baby becomes a little older, you can start teaching your child how to be more patient. Harriet Webster, in the April 1993 issue of Working Mother magazine, looks at ways that you can work with your baby or small child. Ms. Webster says that you can help your child become more patient, but the key is not to expect too much from your child.
While your child is still a baby, try to find a balance between meeting your baby's needs quickly, and teaching your baby how to deal with frustration.
Once your child is a toddler, understand that it is almost impossible for them to stay still. Try to avoid situations where your child needs to stay quiet for a long time. If you can't, realize that your child can't stay still forever.
Ms. Webster has her own tips
for teaching children patience:
Avoid pushing your child beyond his or her abilities: Children have different limits at different ages. Don't set your child up for failure by insisting on too much.
If you need help dealing with your kids, call the following agencies in Erie County. They can help you figure out how to cope with your kids without shaking them.
Parents Anonymous: 892-2172
EPIC: 884-4064
Child and Family Services: 842-2750
Central Referral: 851-5555
Honorary Dandelion
Juju Thomas
Joju Thomas is our honorary Dandelion of the month. We call him honorary because although many individuals are dandelions due to unforeseen circumstances and events, Joju became a Dandelion by choice.
Joju Thomas was a Jesuit Volunteer with Project Dandelion for one year. Jesuit Volunteers are individuals who, after graduating from college, give one year of their life to work in poverty stricken areas throughout the United States. One might think of them as sort of an "urban Peace Corps". During their placement, Jesuit Volunteers (sometimes called JVs) work full time for agencies that assist low income individuals in various areas of service. They receive a small stipend, out of which they have to pay their rent, utilities, food, clothing and transportation. The amount is about equal to what they may have obtained if they were receiving public assistance.
Joju, whose father is a doctor and mom a real estate agent, admits that he led a pretty sheltered life. "Just a little!," he interjects. "Seriously, I came here absolutely naive about the way the real world works. This year has opened my eyes to things and people that I probably would never have come across if I did not spend a year here."
Joju lived with four other individuals on Pennsylvania Avenue, located on Buffalo's lower West Side. He loved the kids in the neighborhood and played with them all the time. Whether it was using "super-soakers" or just sitting on the porch listening to what they had to say-- you could tell the kids loved Jo very much.
While working with Project Dandelion as a Paralegal/babysitter/ counselor/cook/salesman/moving man/outreach liaison...and much, much more, Jo proved that no task was ever too small or too great.
He helped whenever he could wherever he could. He held babies at meetings so that parents could get needed information. He helped move a client's furniture to another apartment when she did not have the finances to hire movers. From cooking rice and beans for Dandelion Potlucks to writing articles and representing clients at hearings, Jo proved himself to be an extraordinary person. During one his more stressful times, Jo assisted a client who was emotionally distressed about not receiving her benefits for several months. The client is now not only receiving her benefits, but she is back in school and receiving day care assistance for her 8-month old daughter. In addition, the client is working with Project Dandelion and a mentor from another agency towards attaining self-sufficiency and emotional stability.
Jo says that he enjoyed working with Project Dandelion. He states, "Dandelion is such a great idea. I hope the future shines brightly on all the Dandelions and that they will be able to clear any hurdle that comes their way. After everything I received from them, I only hope that I was able to give something back."
Jo will be going to Northeastern University Law School in the fall and we wish him all the best. He will be sorely missed by both his former co-workers and Dandelions alike.
SECOND TIME AROUND: Part I
Grandparents (or other relatives) who have their grandchildren living with them often need proof of authority in order to get medical care for the children or to enroll the children in school. There are at least 3 ways that a non-parent can have legal authority to act in place of the parents: (1) Power of Attorney; (2) Guardianship; and (3) Custody. We will discuss each of these individually.
POWER OF ATTORNEY
This document is the simplest to obtain as long as the natural parent caring for the child is willing and able to sign the papers. The parent must sign the Power of Attorney in the presence of a Notary and the Notary must sign and stamp the form. The form can be registered in the Erie County Clerk's Office upon the payment of a small fee, but there is no requirement that the form be registered or filed anywhere.
The Power of Attorney gives the grandparent the authority to deal with health care providers, schools, agencies etc. The advantage of the Power of Attorney is that it doesn't require the consent of both parents and it does not require going to court. There is no need to show that the parents aren't able to care for their children. The big disadvantage is that the parent consenting to the Power of Attorney is free to revoke the Power of Attorney at any time, just by notifying the grandparent in writing. In addition, some schools and agencies will not accept the Power of Attorney as proof that the grandparent can act on behalf of the child. In these instances, one might want to contact our office or come to a Tuesday Meeting.
NEXT ISSUE: WHEN GUARDIANSHIP OR CUSTODY MAY BE NECESSARY
PEOPLE
LIKE YOU
People like you make life special
You always have that way of wearing a smile
encouraging a soul
of always wanting to pray
People like you are life's Jewels
the glitter and the shine
the bright spots always shinning
in people's lives like mine
People like you always show me
more about God's grace...
BECAUSE
People like you possess in them
a portion of God's face
People like you are testimonies
to all that we may not see
People like you have made this walk so very
much richer for
People like Me.
&emdash;
Geraldine Wilson
Dedicated to our Jesuit Volunteers &emdash;
people who have dared to be different & break away from the "norm"
&emdash;From all the Dandelions you have helped.....THANKS!!!
You will always be remembered.
"Representing Yourself in
Child Support Cases"
A FREE Community Education Program
THIS WORKSHOP WILL FOCUS ON:
walking people through the entire child support proceeding including basic information on how to file a petition, where to check-in at court and what documents to bring. The seminar will also include: obtaining a child support order for the first time; how to request an increase in child support; and how to file a violation petition. This will be presented in easy to understand language with opportunity for questions
Saturday, September 20, 1997
St. James United Church of Christ
76 Main Street, Hamburg, New York
10:00 AM until Noon
St. James will provide free
child care and light refreshments
Call (716) 847-0650 ext 217 to Register
Dandelion meetings are held on
Tuesdays at
Neighborhood Legal Services, Inc.
Ellicott Square Bldg. · 295 Main Street, Rm 495
Buffalo, NY 14203
Tuesday Meetings 1:00 - 2:30 P.M.
SEPT. 23 SMALL CLAIMS COURT WORKSHOP
SEPT. 30 ADVOCACY SKILLS
OCT. 13 TIME MANAGEMENT
Tuesday Evenings: 5:30 - 7:00 P.M.
SEPT. 23 BENEFITS COUNSELING
PA BUDGETING:
What will my public assistance benefits look like once I get a job?
SEPT. 30 CLEANING UP YOUR CREDIT
Debt harassment; deferred payment agreements;student loans; budgeting, etc., and other
consumer issues