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Medicaid Beneficiaries Sue Over Implementation of Medicaid Managed Care Program

Thursday, September 24, 2015

On August 27th, a lawsuit was filed against the Agency for Health Care Administration (AHCA) on behalf of five individuals enrolled in Florida’s new Statewide Medicaid Managed Care Long-term Care (LTC) Program. All five named Plaintiffs are elderly, have a disability – or both – with health care needs that would otherwise require care in a nursing home. In response, each client has enrolled in the LTC Program to receive similar levels of care at home.

However, since enrolling in Florida’s Medicaid Managed Care Program, the Plaintiffs have found that there are few standards outlining the types and amounts of services they can receive while enrolled in the program. Without adequate care-planning, or information specifying the available services, important service decisions have been made by Plaintiffs’ managed care organizations (MCOs) that instead ignore critical issues such as individual need, caregiver availability, or the Plaintiffs’ ability to access the community. As a result, the Plaintiffs have been placed at a substantial risk of institutionalization, undermining the purpose of the LTC program itself.

Nancy E. Wright, Esq., and Disability Rights Florida, Florida’s federally mandated protection and advocacy organization for persons with disabilities, represent the Plaintiffs, joined by Southern Legal Counsel. The suit, filed in the U.S. District court for the Northern District of Florida, alleges that AHCA has violated the Americans with Disabilities Act by failing to adequately administer the program and set standards to ensure enrollees such as Plaintiffs will receive sufficient home and community-based services to ensure their health and safety.

Each of the Plaintiffs named in the lawsuit have experienced significant amounts of inconsistency thus far in the MCOs’ attempts to assess their service needs. Despite being proposed for severe and inconsistent service reductions, the lawsuit alleges that none of the Plaintiffs were provided with adequate case management or information regarding the services available to them as enrollees.

One Plaintiff, Adriana Parrales, an intelligent young woman with a rare genetic disorder, was subjected to arbitrary reductions upon transitioning into managed care. Such disparity in service authorizations among Ms. Parrales’s MCOs jeopardized her health and safety, and placed her at risk of unnecessary institutionalization. When a hospitalization necessitated Ms. Parrales’s use of a ventilator, her mother and sole caregiver was informed that her daughter would not be offered private duty nursing or respiratory therapy. Ms. Parrales’s mother was therefore required to provide round-the-clock care for her daughter for several months.

Plaintiffs allege that AHCA’s failure to establish adequate standards for the MCOs authorizing Medicaid recipients’ services in order to address the total care needs of each client effectively negates the overarching goal of any Medicaid home and community-based service program: to prevent or delay enrollee institutionalization. 

Ms. Wright stated, “When AHCA hasn’t made clear the requirements of the program, every aspect of the program suffers, from care-planning to decision-making. This leaves each Plaintiff at continual risk of institutionalization, in violation of the Americans with Disabilities Act.” Bryan Funk, an attorney with Disability Rights Florida, added, “The goal of this Medicaid program is to allow individuals with disabilities to live a life with dignity in their community, surrounded by their friends and family. We want to see that goal achieved.”

Disability Rights Florida has been advocating for access to services, education, employment, independence, and the elimination of abuse and neglect for over 35 years.

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Tags for this Post

agency for health care administration, litigation, managed care, medicaid,

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