Georgia Medicaid program challenged in courts

A federal trial court rules the state cannot deny medically necessary services to children. A separate lawsuit on Medicaid appeals is pending.

By Amy Lynn Sorrel — Posted Sept. 1, 2008

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Georgia's Medicaid program has come under fire from patient advocacy groups in a pair of lawsuits alleging shortfalls within the system that could jeopardize access to care for disabled beneficiaries.

In one case, a federal trial court in June ruled that the state does not have the authority to reduce the amount of Early and Periodic Screening, Diagnostic, and Treatment services prescribed by a physician to child beneficiaries.

Twelve-year-old Anna C. Moore's doctor prescribed 94 hours a week of private skilled nursing care for the child, who has severe disabilities from cerebral palsy, spinal deformities and other chronic conditions, in addition to being blind and nonverbal. In November 2006, the state Dept. of Community Health approved only 84 hours of care. Moore's mother, who had appealed similar cuts before, sued the department in December 2006.

While states may have leeway in some areas when it comes to deciding adult Medicaid coverage, a 1989 amendment to the Medicaid Act mandates that states provide EPSDT services as needed "to correct or ameliorate" any condition discovered in the course of the screen, said Joshua Norris, director of legal advocacy for the private-sector Georgia Advocacy Office, which represented Moore.

"A state Medicaid agency is permitted a right to review prescribed treatment, but it is not supposed to be using that as a means to deny necessary treatments," Norris said. "Treating physicians are the ones that get to decide this issue of medical necessity," not the state, he said.

The U.S. District Court for the Northern District of Georgia in Atlanta agreed, citing similar decisions out of the 5th and 11th U.S. Circuit Courts of Appeals.

Meanwhile, in a separate case in the Superior Court of Fulton County, three adults with disabilities and Medicaid coverage allege the Dept. of Community Health unfairly delayed their appeals of coverage denials.

Federal and state Medicaid rules require a fair and prompt hearing, as well as a final decision, within 90 days of an appeal filing, said Charles R. Bliss, director of advocacy for the Atlanta Legal Aid Society. ALAS filed the lawsuit along with the Georgia Legal Services Program.

But some patients waited as long as six months before having a hearing scheduled, while others still await a response from the state, the complaint said. Plaintiff Drew Joseph, 32, has ataxia due to a brain tumor he has had since birth. After Joseph received additional neurological injury from a fall, his neurologist wrote a letter requesting increased in-home nursing care. The state denied the request in February, and Joseph appealed. Despite three follow-up letters he sent to the department, it still had not processed his request by the time the lawsuit was filed in late June.

Appeals and access at issue

The delays have affected hundreds of patients with disabilities around the state "who are being denied necessary care, and with no way to contest the denial, they have no recourse," Bliss said. "These are serious medical issues, and we need to make sure [Medicaid patients] get access in a prompt way because their lives are at risk without it." The Dept. of Community Health declined to comment on the ongoing litigation.

In documents filed in the district court, the department argued that it is not refusing to provide EPSDT services. Rather, the state asserted that it had exercised its "rightful discretion to determine the amount, duration and scope" of the treatment. The agency is appealing the district court ruling to the 11th Circuit.

On the issue of pending appeals, department spokeswoman Matia Edwards acknowledged a backlog. "The Georgia Dept. of Community Health understands the importance of the timely review of appeal cases and recognizes the impact [the backlog] has on our member and provider communities," she said. The agency has implemented a plan to increase staff to help transmit hearing requests more expeditiously to the Office of State Administrative Hearings and adjudicate the appeals once received.

The Medical Assn. of Georgia is not involved in either case but continues to monitor them. President-elect M. Todd Williamson, MD, said the access-to-care issues are compounded by low Medicaid reimbursement rates, which continue to deter many physicians -- particularly pediatricians, ob-gyns and other specialists -- from taking new Medicaid patients.

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Case at a glance

Can a state Medicaid program reduce the amount of EPSDT services prescribed by a physician?

A federal trial court in Georgia said no.

Impact: Patient advocates say the decision affirms that doctors should be deciding medically necessary treatment for Medicaid children, not the state. Georgia's Dept. of Community Health maintains that it has the authority to limit the level of such treatment.

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