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May 1998
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May 1998
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By Susan Goodman, Esq.A class action lawsuit has been filed against the Secretary of the Department of Public Welfare (DPW) in the state of Pennsylvania. The DPW administers the state Medical Assistance program and must insure that organizations providing health care services to Medicaid recipients follow the rules of the federal Medicaid program. The representatives of the "class" include individuals with disabilities who charge that:
They have not received timely and adequate notice informing them of decisions made by their Health Maintenance Organization (HMO).
The HMO is violating federal law by not considering the "medical necessity" of "home health services" and "assistive technology," as required by federal law.
This means that the Secretary of DPW has failed to require the HMO, in which Medicaid recipients are enrolled, to follow the federal Medicaid law - thus illegally denying services to these recipients. According to the state of Pennsylvania, a service benefit must be considered medically necessary and allowed if:
"The service or benefit will, or is reasonably expected to prevent the onset of all illness, condition, or disability;
The service or benefit will, or is reasonably expected to reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability; or,
The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age."
The lawsuit charges that the HMOs are disregarding the legal medical-necessity requirement and are using rules that differ with and are narrower than the state definition. The individuals with disabilities representing the "class" include an individual who needs an assistive listening device, a motorized scooter, several individuals who need skilled nursing services, and an individual who needs physical therapy services.
A thirty-eight-year-old woman, S.M., who developed Reflex Sympathetic Dystrophy after a car accident, requested a new motorized scooter. The motorized scooter she had been using allowed was no longer working properly. It began to just shut itself off without warning and this would happen at any time, including in the middle of a street, a mile or more from her home or while shopping. In her application for a new motorized scooter, S.M. stated that a new scooter would enable her to maintain her independence in activities of daily living (ADLs) and community activity. The HMO denied this request stating that the motorized scooter was not "medically necessary." It did not state what requirements it used in determining "medical necessity."
Another individual representing the "class" is a nine-year-old boy, J.M., who has severe to profound hearing loss in his right ear. An audiologist recommended that he be given the chance to use a FM trainer (a special type of hearing aid that enables an individual to hear sounds transmitted from specially placed microphones by using FM signals). J.M used this device for four weeks - during which time his ability to focus and participate in conversation improved. An application for the FM device was presented to the HMO and was denied because the device was not listed on the fee schedule. Notice of the right to appeal was not provided to J.M's family.
These are just a few examples of how AT is denied using "medical necessity" as an excuse. We will keep you posted on further developments in this case.
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