I have now battled 2 states on many Medicaid issues and won every one based on clear, plain language statute. There should have been no argument. It was made difficult as Information was hidden from me, misinformation given to me, and inquiries not responded to. I can not get passed the gatekeepers where an attorney could. Every attorney, every firm tells me that they only deal with finance planning and eligibility, and the system is too broken and to large for their resources. I am just a retired electrician and I am winning landmark cases, but my wife requires my 24/7 care and attention. It astounds me, as I win each case, that our much criticized Congress has really legislated great programs for us for many years, but they are prevented by the state administrators. What Congress has intended is not reflected in state programs and the beneficiary is cheated, the service providers are cheated, the logistics for continuance of the programs are cheated, and Congress is cheated because they are blamed for the supposedly inadequate Medicaid program. Here is a recent example. Congress has legislated caregiver respite hours for family caregivers. 600 hours per year in this state.This Managed Care Contractor got the idea that respite can not be provided on the same day as attendant care, no matter what times or how many hours. The MCC has had this self made policy for over 15 years. That is a lot of caregivers, paid care workers, agencies, the program, cheated while the MCC kept the money designated bu Congress for the service. The MCC was not only allowed, but encouraged by the State Medicaid Authority to do so in spite of plain state policy.
AMPM 1250-7 page 89
If respite care is provided in the member’s own home, all HCB services included in the member’s service plan may be provided in conjunction with respite care. Examples are as follows:
1. If the member is receiving personal care services, he/she may continue to receive this service in conjunction with the respite care.
I had battled another state where they had installed a new 15 million dollar system and over the years of programming, the IT people didn't thing that that the special considerations for elderly/disabled were priority. In court they testified that they considered that EPD codes were low priority because they had been little used. The judge was astute and said that it is obvious that they were little used because the system didn't contain them, thus the caseworkers didn't know of them. The state admin had not properly monitored for over 12 years and many people were cheated. That secretary stepped down after that. As I visit caregiver sites I see many of the complaints that I have won. The states have many choices and latitude in the administering of Medicaid benefits and each state is different, but there are some things that are federally mandatory. I just read a comment where someone needed attendant care and the state contractor was not providing it. I downloaded that states regulations and the contractor is wrong in the denial, but the state admin is clueless. Here is what has happened in my state for over 15 years. Again, that is many people cheated while the contractor kept Medicaid funds. This is from a well know long running case begun in 2001 and nothing has changed, as no one has effectively challenged. The state admin gets paid by our taxes to monitor. Ball vs Rogers page 29 line 5
""""Once an ALTCS contract has been signed, AHCCCS leaves most of the responsibility for determining whether beneficiaries actually receive prescribed services up to the program contractors themselves. Dep. of Shafer, 118:14-22.
During the two years in which this lawsuit has been pending, no program contractor has been given a poor performance rating or otherwise penalized for failing to fill beneficiary care plans. Id., 140-141.""""
Ball vs Rogers page10 line 9
""""ALTCS program contractors are allowed to keep the profit that they make by not spending all of their capitation payments on services. Statement of Facts, ¶¶ 116, 119.""""
Ball vs Rogers page 14 line 8
ALTCS Fails To Effectively Monitor Its Program Contractors
The AHCCCS managed care system creates an incentive to
underserve beneficiaries. ALTCS program contractors make more profit if they provide fewer services to the members. Deposition of Mark Hoy 45:1-3, 22-23.
So. Congress intends much more than we are receiving.The statutes are plain even to this retired electrician. Why are attorneys unwilling to battle for the people?