Slow and Unfair Medicaid Appeals Prompt Lawsuits
If you are an individual receiving Medicaid benefits there are various rights that you are entitled to. For example, if your are denied services for any reason, you are entitled to appeal the decision. The appeal is supposed to be addressed within 90 days from the time it is filed.
Since Medicaid is a program which is jointly funded by state and federal funds, there are definite rules that govern appeals and decisions. In Georgia, where many lawsuits have been filed – especially by and on behalf of individuals with disabilities who have been denied the right to a timely appeal.
Some lawsuits which have been filed against the officials of the Department of Community Health allege that Medicaid has been violating both state and federal law by delaying hearings for people with disabilities who have appealed decisions about their care. The lawsuit states that hundreds of Georgians – many of them disabled – have been subjected to extremely long waits that are illegal trying to get hearings for their appeals of medical services that they have been denied.
The most unfortunate part of this situation is that while there are “backlogs” and delays, individuals are not receiving the care that they desperately need, so in many cases, their health declines, eventually costing Medicaid more money.
Some examples of this situation are:
• An individual who is a paraplegic with other health issues needs 4 more hours per day of home health care or she will have to return to a nursing home which would cost many times the expense of extra home care. Medicare declined her latest request in January and she appealed in February. Her appeal has still not been heard and it is nearly August. Her case has not even been sent to the office that hears appeals.
• A second plaintiff in an individual with Multiple Sclerosis who has been living in a nursing home. He would like to be in his own apartment because it is a better environment for him and a much better environment for his children. Living in an apartment and receiving home health care would be far more cost efficient than the nursing home. He has been waiting since early March for a hearing regarding his appeal.
These are just two cases in a sea of backlogged appeals. While individuals suffer delay after delay, Medicaid continues to spend more money on services that are not necessarily appropriate or cost effective for too many people in the system. The decisions in these and other cases will hopefully set a precedent and turn the process around so that it is efficient, effective and helpful for those who are depending on it to help them enhance their lives.
