An ALS patient overcame a healthcare roadblock with the help from the Action News Troubleshooters.
Sometimes to get the care you or a loved one needs, you have to overcome major roadblocks and cut through red tape and that is not easy. And that is exactly why the Troubleshooters are here to help.
Gregg Lipschultz's body is failing but his mind is as sharp as ever. That is the painful reality of ALS, also known as Lou Gehrig's disease.
"This disease is the worst. This is the worst disease imaginable. It's brutal and relentless. I need help," said Lipschultz.
When we first met Lipschultz, he communicated using his thumb to text. Six months later, he can only type with his eyes.
"You get to watch your body shut down and there's nothing you can do about it," he said.
When Lipschultz was diagnosed at 46 years old, he was a vibrant, active man who loved sports. Within six months, he was bedridden.
"He's choking at night. He's on a catheter. He progressed to needing a feeding tube," said his aunt and caretaker Joan Feinstein.
Feinstein reached out to the Troubleshooters, desperate to get him 24-hour care and frustrated with a state waiver process that, she said, is incredibly difficult to navigate or even understand.
"I'm frantic. My nephew needs care. They say 'there's no application, go to the back of the line and start all over,'" she explained.
The Action News Troubleshooter who worked tirelessly on Lipschultz's case is volunteer Lance Haver.
"She had been putting the application in with the wrong people in the wrong place and nobody told her that there's an emergency protocol," said Haver.
Here's what you need to do if you have a loved one in a similar situation.
"Go immediately to the Office of Long Term Living and make sure that the application is approved," said Haver.
And if you're still having trouble, call the Troubleshooters.
"Call us. We'll advocate for you like we advocated for Gregg, and most times we will be successful," said Haver.
"Once Action News got involved, everything started to move. I can't tell you how many phone calls I got. They said they had orders from their higher-ups to expedite his situation," said Feinstein. "He has not one but two aids and actually, he's getting approved now for a skilled nurse."
"Absolutely from the bottom of my heart, I would personally like to thank whomever made it possible for me to get the care I so desperately needed," said Lipschultz. "Without people like Lance and the whole Troubleshooters team, I'm quite certain I would still have people like my aunt still fighting."
"So today, we have some hope," said Feinstein. "Thank you from the bottom of our hearts. I don't know if Gregg would be here with us if it wasn't for you."
The state declined an on-camera interview but wrote, "An average processing time for expedited applications is not available. It is always the goal to complete expedited applications a quickly as possible."
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It also said the Department of Human Services is "looking for ways to improve the efficiency and effectiveness of its systems."
The Pennsylvania Department of Human Services released this statement to Action News:
"While HIPPA precludes the department from commenting on specific cases, our Office of Long-Term Living works to expedite applications for Medicaid in urgent situations.
Some additional information about the process: Adults who are dually eligible for Medicare and Medicaid or adults 21+ with a physical disability requiring long-term services and support must apply for these services through the Department of Human Services' Independent Enrollment Broker (IEB), Maximus. Service providers, including service coordination entities, should always refer people to Maximus directly for enrollment and application help. If an individual or a family member does not apply directly through Maximus, DHS' Office of Long-Term Living has no way to monitor the application status.
Applications take, on average, about 50 to 60 days to process at this time. In addition to working to expedite urgent cases, the Office of Long-Term Living is also actively working with Maximus to enhance efficiencies wherever possible to shorten the application period for individuals who qualify for long-term services and supports."
Q&A with PA Department of Human Services:
What is the process if a family wants to get an application for Medicaid expedited due to an urgent situation?
The applicant/representative can notify the state's independent enrollment broker (IEB) of the urgent need. There is one statewide contract for the PA IEB, which is Maximus. An applicant may contact the PA IEB at +1 (877) 550-4227 or https://www.paieb.com to start the application process.
Who works to expedite such applications? How many applications do you receive on average per month and/or per year with the request to expedite?
The IEB coordinates all entities involved in the application process when an expedited application is identified. Those entities include the Assessment Agency, the applicant's physician and the County Assistance Office. Average monthly or annual data for expedited applications are not available.
How long do applications NORMALLY take to process?
The current average timeframe for completing an application is 52 days.
What is the goal for processing time of expedited applications? What is the actual time it takes right now?
It is always the goal to complete expedited applications in the shortest timeframe possible. All information including documentation required to make a financial eligibility determination must be received for an application to be completed. An average processing time for expedited applications is not available. It is always the goal to complete expedited applications as quickly as possible. However, each case has its own complexities and all applications must be treated on a case-by-case basis.
How many complaints does the Office receive about application times and issues?
From July through October 2019, the Office of Long Term Living has received an average of 116 inquiries per month in regards to eligibility and enrollment. This is down from an average of 261 per month during the same timeframe in 2018. The data is for all complaints/concerns related to eligibility and enrollment. Specific complaints may be about application status inquiries, denials, loss of eligibility, etc.
What can families do if they believe they are getting stuck in the system.. or getting the runaround?
An applicant may contact the PA IEB at +1 (877) 550-4227 or the OLTL Participant Helpline at 1-800-757-5042.
Is the Office of Long-Term Living working to enhance efficiencies? What is the Office doing?
OLTL recently released a Request for Information (RFI) on a draft Request for Application (RFA) for enrollment services. One of the intents of the proposed revisions for enrollment services is to address key opportunities for improvement within the process, one of which will be the process to address expedited applications. The Department of Human Services is always looking for ways to improve the efficiency and effectiveness of its systems.
Action News Troubleshooters gets healthcare help for ALS patient