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February 2004 - CLIENT ADVISORY LITIGATION INVOLVING MEDICAID REIMBURSEMENT |
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Patients Right to Access Providers This suit was brought by several developmentally disabled adults seeking injunctive relief against state officials, including the Governor, for alleged violations of the Americans with Disabilities Act (ADA), the federal Medicaid statute and the Rehabilitation Act. The plaintiffs, who lived in the metropolitan Chicago area, sought to live in Intermediate Care Facilities for the Developmentally Disabled (ICF/DD’s). However, since the Chicago area facilities had no vacancies, only ICF/DD’s located in the southern part of the State could accept the plaintiffs. The plaintiffs argued unsuccessfully that the State violated the Medicaid Act by failing to provide identical service statewide because the vacancy rate was lower in the southern part of the State. The Court held that a State Medicaid Plan is not required to assure identical convenience of service everywhere in the State. The Court also noted that the lack of available facilities did not violate plaintiffs’ right under the Medicaid Act to freedom of choice among providers. According to the Court, the aim of this provision is to give Medicaid recipients a choice among available facilities, not to require the creation of new facilities. See Bruggeman v. Blagojevich, 324 F.3d 906, 908-09 (7th Cir. 2003) On January 8, 2004, the plaintiffs returned to Court alleging that the State failed to obtain federal matching and Medicaid funds for programs involving the developmentally disabled. The plaintiffs requested that the Court order the State to produce all documents related to the extent the State failed to obtain available federal matching and Medicaid finds. The Court ruled that the plaintiffs were only entitled to review the State's current or future mental health budget proposals. See Bruggeman v. Blagojevich, No. 00 C 5392 (N.D. Ill. Jan. 8, 2004) Prescription Drug Cap According to the 10th Circuit Court of Appeals, the state of Oklahoma may have violated the Americans with Disabilities Act (ADA) by implementing a prescription drug cap for participants in its Medicaid home and community-based services waiver program. Program participants brought suit against the State agency claiming its decision to limit prescription medications for participants in the waiver program to five per month, while continuing to provide unlimited prescriptions to patients in nursing facilities, violated the integration mandates of the ADA by forcing participants out of their communities and into nursing homes. Prior to the imposition of the prescription cap, Medicaid recipients had been entitled to an unlimited number of medically necessary prescriptions. The defendants sought to dismiss the claim. However the Court concluded that the plaintiffs may have a meritorious ADA claim against the State. The Court remanded the case to the lower court for further consideration. See Fisher v. Oklahoma Health Care Authority. No. 02-5192 (10th Cir. July 15, 2003) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services On November 6, 2003, the Federal Court of Appeals in the 7th Circuit Court held that the federal Medicaid Act requires states to provide coverage for the treatment of children in psychiatric residential treatment facilities. The Federal Medicaid Statute requires states to provide Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services to Medicaid-eligible children under the age of 21. EPSDT services are defined as any treatment which a physician finds necessary as a result of a diagnosis made at a preventative health care screening, including treatment for mental illness. This case was brought in Indiana as a class action lawsuit against the State. The plaintiffs alleged that the State failed to provide coverage as required by the Medicaid Act for psychiatric services in a residential treatment facility. Indiana’s Medicaid plan only provided coverage for the outpatient treatment of mental illness. The Court of Appeals ruled that since EPSDT expressly covers inpatient treatment for children who have been screened and found to have a mental illness for which treatment is medically necessary, the Indiana Medicaid Plan must provide coverage for residential treatment. See Collins v. Hamilton, 2003 WL 22511144 (7th Cir. Nov. 6, 2003) |