Legal Assistance in Health Care Financing
With funding from the Wisconsin Trust Account Fund, ABC for Health provides direct legal representation and advice to low-income families facing denials of health care coverage and services. ABC is often the only source of legal assistance available for families encountering obstacles as they seek necessary health care services and coverage, or attempt to exercise their legal rights within the health care system.
Health Benefits Counseling Services at St. Mary’s Hospital and Meriter Hospital
ABC for Health provides hands-on technical assistance through Health Benefits Counseling to help un- and under-insured patients link to health care coverage resources. Even expert provider staff are not likely to have the time to keep up with many complicated benefit programs and rules. Yet, time is of the essence for patients to gain eligibility for complicated and nuanced programs. Proactive Health Benefits Counseling is a winning formula to maximize third party reimbursements while serving the needs of patients. To date, in a contract with ABC for Health since October 2005, St. Mary’s has received an average of $30 in reimbursements for every $1 paid for Health Benefits Counseling. Partnering with ABC since December 2010, Meriter Hospital in Madison has received an average of $18 in reimbursements for every $1 paid for Health Benefits Counseling. Click here (.pdf) for more information on the partnership with St. Mary's.
ABC3 (Competency, Capacity, and Coordination)
ABC3 is an enhanced training, networking, referral, and direct service project for Children and Youth with Special Health Care Needs (CYSHCN). ABC for Health’s attorneys and advocates work with statewide CYSHCN collaborators, Regional Centers for CYSHCN, and other key partners to address the needs of CYSHCN and their families in accessing, maintaining, and using the most appropriate form of health care coverage. As part of the project, ABC provides benefits counselors, Regional Centers, and collaborators with training and education. In addition, ABC provides direct health benefits counseling to under- and uninsured individuals. A MCH Title V Services Block Grant, Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services helps support this project.
The Changing Landscape of Health Insurance in Wisconsin after Reform
ABC for Health, with support from the Wisconsin Law Foundation and in partnership with HealthWatch Wisconsin, produced a workshop and guidebook on private insurance and national health reform. The workshop and the guidebook are for legal and health care professionals, consumer advocates, and health care consumers. The materials provide practical tips and explanations that help Wisconsin families enroll in health insurance and challenge inappropriate health coverage denials.
The Pathway Plan for 2012
"The Pathway Plan for 2012" is a creative and cost effective public-private partnership and an alternative to Wisconsin’s Department of Health Services Waiver proposal to CMS that drastically restructures and limits or eliminates coverage for many BadgerCare and Medicaid recipients. Bobby Peterson, public interest attorney, director of ABC for Health, and author of the plan implored the Joint Finance Committee to take a smarter approach and examine better alternatives to the DHS plan that rips massive holes in the successful BadgerCare pool.Peterson says the Pathway Plan for 2012 could eventually cover all Wisconsin residents while providing high-quality care, continued choice, and strong consumer protections. Read more here.
Monitoring Blue Cross Blue Shield Conversion Funds
Over a decade ago, Blue Cross Blue Shield of Wisconsin converted from a nonprofit health insurance provider to a for-profit business. As part of the conversion, Insurance Commissioner Connie O’Connell required that Blue Cross Blue Shield pay back to the public the more than $600 million in community benefits as a result of its tax-exempt status since the 1930’s. The Commissioner directed the $600 million of public money to Wisconsin’s two medical schools, the Medical College of Wisconsin and the University of Wisconsin School of Medicine and Public Health, and she ordered the schools to use the funds to "promote public health initiatives that will generally benefit the Wisconsin population." ABC for Health monitors the schools’ use of the Blue Cross Blue Shield conversion funds and advocates for increased funds for the public health community and the people of Wisconsin. Click here for more information.
Children’s Health Insurance Program Reauthorization Act Project
This project, funded by the Children’s Health Insurance Program Reauthorization Act (CHIPRA), aims to increase the number of children enrolled in health care coverage programs. To help achieve this aim, ABC for Health will improve the scope and effectiveness of HealthWatch Coalitions across Wisconsin. Efficient, coordinated advocacy and enrollment in public safety-net programs begins with competent, up-to-date public health professionals working directly with families. The statewide HealthWatch Wisconsin organization will promote the CHIPRA project through an existing network of community-based coalitions in nine counties, connect health care workers across the state, and facilitate the development of local strategies to reduce barriers to enrollment. Learn more at HealthWatch Wisconsin’s website: www.healthwatchwisconsin.org. A Children’s Health Insurance Program Reauthorization Act Outreach and Enrollment Grant, HHS-2009-CMS-CHIPRA-0008, supports the CHIPRA project.
Connect WI: LifeLine and Link-Up Services
Connect WI is an outreach project of ABC for Health and HealthWatch Wisconsin to inform Wisconsin residents about the federal Lifeline and Link-Up programs, which provide affordable telephone service for low-income residents. Through daily communications with clients, and through the HealthWatch Wisconsin e-newsletter "The HealthWatch Update," ABC for Health is reaching a rapidly expanding population of Wisconsin residents eligible for Lifeline and Link-up services. To view ABC's educational video about Lifeline and Link-up, click here
Consumer Assistance Partnership
In partnership with the Wisconsin Office of the Commissioner of Insurance, ABC for Health educates and advocates for consumers of health insurance. ABC helps consumers enroll in health coverage programs and educates them about their rights and responsibilities under different insurance options. ABC also advocates on behalf of consumers at various stages of internal grievance proceedings in state and federally regulated private insurance disputes, in Medicaid fair-hearings, and in state and federal court, and helps consumers conduct appeals and grievances. A Department of Health and Human Services, Office of Consumer Information and Insurance Oversight Affordable Care Act (ACA) – Consumer Assistance Program Grant helps support this project. ABC limits funding to support consumers that do not have other available assistance. This grant does not support the direct delivery of legal services.
The Commissioner of Insurance, Ted Nickel, has terminated this program. Click here to read more.
Sharon Mondry contacted ABC for Health after her insurance company refused to cover her son’s speech therapy. Her son, Zev, had stopped talking as a toddler. His doctors diagnosed him with autism and recommended that speech therapy would help him regain some ability to speak. Sharon and ABC repeatedly asked the insurance company to justify the refusal of coverage, but the company would not provide the documents it used as the basis of the coverage denial. In 2006, Sharon and ABC took the insurance company to court. In the lawsuit, eventually appealed to the U.S. Supreme Court, ABC’s Executive Director and public interest attorney Bobby Peterson argued that the insurance company was legally obliged to provide the documents used to deny coverage of Zev’s speech therapy. The Seventh Circuit Court of Appeals agreed. The Court's decision, which still stands today, noted that health plans cannot "hide the ball" from plan participants and withhold the documents they need in order to appeal benefits denials. Sharon’s court case is not over yet. A few legal questions about fines and attorney’s fees remain to be resolved. But already her victory will ensure that other families fighting a benefits denial will not face similar refusals before they get plan documents they need to appeal a denial of services.