The Solution: Provide Education and Legal Representation to Vulnerable Groups

PHLP uses the law to secure health rights through direct representation, community education, and systemic advocacy on behalf of low-income Pennsylvanians. Through its two decades of advocacy, PHLP has developed a deep understanding of the interface (in eligibility, payment liability, covered services, and provider networks) among the many programs as well as the federal, state, and local laws, regulations, policy directives, and contracts that define its clients’ healthcare rights.

PHLP’s free legal services make it easy for consumers to seek individual representation when they are denied coverage. All Helpline callers receive careful legal counsel to help them through their problems, including verbal advice, written materials and resources, communications with health programs and providers, and representation at various types of hearings in the healthcare setting.  Through its Helpline, newsletters, list serves, public trainings and presentations, website, brochures, and flyers, PHLP breaks down the barriers that prevent consumers from receiving health care coverage and services.  The most innovative components of PHLP’s model include:

• Scale: PHLP offers statewide coverage across Pennsylvania and assists several national-level organizations.
• Focus: PHLP’s programs and initiatives focus on service denials to vulnerable groups such as the poor, disabled, and elderly.
• Reach: PHLP has developed innovative mechanisms to access its target constituents in cost-effective and focused ways.
• Delivery: PHLP’s unique telephone-based service delivery model is tailored to overcome the financial and mobility constraints of its target constituents.
• Impact: In recent years, PHLP has elevated health care as a social justice issue.

Scale

PHLP’s constituency includes the 2.1 million low-income Pennsylvanians on Medicaid, more than 174,000 low-income children enrolled in the Children’s Health Insurance Program, and over 54,000 adults in the adultBasic program.  PHLP also receives calls from uninsured Pennsylvanians. In a typical year, more than 3,000 Pennsylvanians call PHLP’s Helpline for individual counseling and representation. Federal healthcare reform will increase the needs for PHLP’s services.

While PHLP’s services focus on Pennsylvanians, it has been a resource for national-level organizations. For instance, PHLP assisted the National Academy of Child Advocacy in writing their Child Health Advocacy manual. On behalf of their clients, PHLP worked closely with the Children’s Defense Fund, the American Association of Retired Persons, and Families USA on national healthcare issues. PHLP also worked with the National Health Law Project during the intense congressional debate over universal health insurance, to analyze the Clinton Plan from the perspective of low-income consumers. Additionally, PHLP attorneys have testified before congressional committees.

Focus

PHLP specifically focuses on issues and individuals that fall beyond the purview of other aid organizations. In its early years, PHLP identified a key shortcoming in the state’s healthcare delivery system. PHLP’s Executive Director Laval Miller-Wilson explains, “There were large numbers of people who had trouble accessing publicly funded healthcare services — in other words, people who were eligible for Medicaid but were being denied medically necessary services.  Other legal aid programs could get people eligible for Medicaid, but there wasn’t enough legal help available to those who had a service denied, reduced, or terminated. We realized that someone needs to step in to plug this gap.”  PHLP is the only legal service organization that focuses exclusively on healthcare coverage eligibility and service denials.

PHLP serves customers who are both above and below the federal poverty level. By advocating for a range of clients, PHLP addresses the needs of those citizens who are ineligible for the local legal aid service agencies such as Pennsylvania Legal Aid and Community Legal Services. PHLP’s Helpline benefits Pennsylvanians who find it difficult to obtain counsel for their grievances. Additionally, such consumers are typically declined services by private legal service providers because of their low income and low profitability. The only alternative available to consumers faced with service denials has been to approach member advocates who face a conflict of interest, as the insurance companies employ these advocates.

The poor, disabled, and elderly are especially vulnerable to service denials. Their inability to afford legal representation or get around made it particularly difficult for them to access healthcare benefits that they were eligible for. PHLP’s service model is specifically geared towards serving these groups. The aid PHLP offers makes it possible for low-income groups to obtain knowledgeable counsel, while its over-the-phone legal service delivery model enables the disabled and elderly to overcome their mobility constraints.  In this way PHLP has carved out a unique niche.

Reach

PHLP pioneered an effective way to reach its target constituents by convincing the Department of Public Welfare to make it mandatory to put its Helpline information on denial forms. As a result, those who get a written denial from the Medical Assistance program automatically are informed about PHLP’s free legal representation for appealing the decision and receive PHLP’s contact information. This is a highly effective, targeted, and low-cost way to reach those who are denied healthcare coverage and inform them about PHLP’s services. Additionally, PHLP has developed several touch-points to reach and educate those who face service denials. These include in-person access through its three offices (Philadelphia, Harrisburg, and Pittsburgh), education seminars organized periodically in various counties across the state, and several print and online newsletters and publications.  Miller-Wilson states that “our services are only as effective as our ability to reach those who need them. We strive to get the word out about our program, whether it be through our Helpline, website, or publications. It is encouraging to see what we have achieved without spending a single dollar on advertising, but we are always looking to reach more and more people who are in need.”

Delivery

A key feature of PHLP’s model has been the organization’s ability to provide legal representation over the phone. Those denied services and who wish to appeal the decision can call PHLP’s toll-free Helpline, speak with a PHLP representative, and fax over the relevant documents. PHLP attorneys then conduct legal consultations over the phone, with everything from legal arguments, case documentation, and expert testimony provided over the phone or by fax. In most instances, the entire process of providing legal representation takes place without any in-person contact between the plaintiff, PHLP attorneys, insurance agents, doctors, judges, or other healthcare experts.

PHLP’s innovative approach of delivering legal aid over the phone has enabled information, education, and a helping hand to reach inaccessible geographies and customer groups. The Helpline allows PHLP to have a statewide presence and reach people in remote areas where families may not have easy access to the offices of their local legal aid service providers. Similarly, the Helpline makes it easy for the elderly and the disabled to access legal services.  Says Miller-Wilson, “We are forever on the lookout for ways in which more people can access our services. Our legal services delivery over the phone was a result of this search and continues to bring more and more people to our Helpline every day.”

Impact

Impact litigation and policy influence are cornerstones of PHLP’s impact strategy. Through class-action lawsuits and representation on government policy-making committees, PHLP ensures quality health care.  Thus, in addition to the individual representation described above, PHLP seeks systemic change to prevent the same case from happening again and again.

PHLP has seen some early signs of success with this new strategy of litigating class-action suits. For instance, PHLP brought litigation that resulted in the addition of hundreds of modern medical procedures to Medicaid’s fee schedule when Pennsylvania’s Medicaid program refused to pay for over 800 procedures, including ultrasounds for pregnant women, because the fee schedule had not been updated in nearly 20 years. In the case of the ultrasounds, the state had contended that x-rays were an acceptable alternative (Simpson v. Schweiker). PHLP successfully litigated a class action that restored care to thousands of nursing home patients when the state tried to reduce services (Troutman v. Cohen). PHLP co-counseled the case that restored benefits for hundreds of poor, seriously ill persons, including payment for life-sustaining medication that the state had denied (Lind v. Snider). And PHLP brought the case seeking consumer safeguards when Pennsylvania sought to impose a mandatory managed care program on 650,000 Medicaid recipients without any regulatory protections (Hernandez v. Houstoun).

PHLP has also made significant headway in getting its voice heard within policy-making circles. It serves as staff for the Consumer Subcommittee of the Medical Assistance Advisory Committee that is the voice of Pennsylvania’s 2.1 million Medicaid recipients before the DPW, which administers the Medicaid program.  In this role, PHLP analyzes every proposed regulation, bulletin, and policy initiative that has the potential to affect the delivery of health care to the poor. PHLP also facilitates dialogue between recipients and DPW, the Hospital Association, the Medical Society, and the many other healthcare providers under Medicaid. PHLP drafted the legislation that established the Children’s Health Insurance Program, a Pennsylvania law that expanded health coverage for tens of thousands of low-income children. PHLP also helped the federal Health Care Financing Administration with its guide for Medicare beneficiaries, which compares HMOs offering Medicare coverage.

Miller-Wilson says, “Our grassroots presence and years of service have equipped us with a deep understanding of what the issues are, where they exist, and how they can be addressed. We want to take this knowledge and serve as a bridge between the people and the policy makers. By seeking representation on policy-making committees or by counseling them, we want to share what we are hearing on the ground, inform government policies regarding medical assistance, and magnify the impact of our efforts.”

The scale and reach of PHLP, its focus on vulnerable groups, and unique mode of contactless legal services delivery have all enabled PHLP to make a difference in the lives of those who have been denied services that they are eligible for.