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Medicaid Reasonable Promptness Lawsuit Settled

Monday, October 28, 2013

Wheaton, et al v. APD, Case No. 4:13-cv-00179-MW-CAS

After the March 24, 2011 implementation of the cost plan freeze by the Agency for Persons with Disabilities (APD), Disability Rights Florida began noticing a trend of administrative delay and non-responsiveness by APD towards service requests by clients of the Medicaid Developmental Disability Waiver. APD’s records demonstrated that many requests had gone 90 days or more without a substantive response of whether the service request would be granted or denied. These extended delays presented a significant danger to individuals with developmental disabilities.

On April 4, 2013, Disability Rights Florida, co-counseling with Nancy Wright, Esq., filed a lawsuit in the Federal District Court for the Northern District of Florida on behalf of six named plaintiffs. Disability Rights Florida was also listed as a plaintiff because of its role as the state's federally mandated Protection and Advocacy organization for people with disabilities. The complaint alleged that APD was failing to provide medical assistance to Waiver clients with "reasonable promptness" as required by federal Medicaid law. Each of the individual named plaintiffs had requested services under crisis and had been without a response for over six months. These delays were often a result of agency inaction and/or repeated requests for additional documents or additional evaluations.

The plaintiffs and APD entered a settlement agreement on October 10, 2013 that will have a broad and positive impact on APD’s methodology for tracking and responding to service requests by clients of the DD Waiver. APD has agreed to the following:

1. Timelines - APD must review all requests for an increase in funding under the new timelines set out in the iBudget Rule, F.A.C. 65G-4.0211(6), which requires APD to either approve the requested service(s), deny them or request additional documentation from the client within 30 days of the Agency's receipt of the request. If additional documents are requested, APD must make its decision within 60 days from the initial request.

2. Criteria - APD will also fully adopt the standards for reviewing a service request set out in the iBudget rule, moving away from the "crisis criteria" set out in the "cost plan freeze".

3. Automatic Approval - If APD does not issue a decision within 60 days, the support coordinator or client may notify APD in writing of the delay. If there is still no decision within 20 days from that notification, the request is deemed automatically approved and the client can begin to receive the service. At that point, the service can't be rescinded without notice from the Agency and the opportunity for an appeal.

4. Emergency Funding - In certain cases, and at the discretion of APD's regional personnel, Regional Offices have the authority to provide emergency funding to a client while a service request is under review.

5. Service Request Submission and Tracking - Each APD Regional Office will have a designated email account, published on the APD website, to take service requests. Eventually, this may change to a statewide electronic system. APD is also developing a new tracking system to follow the progress of every request and Disability Rights Florida will be monitoring the progress and timeliness of service requests for a full year.

If you have submitted a request for services from APD and are experiencing problems or encountering delays, you may call us at 1-800-342-0823 to request assistance.

Our services are free and confidential.

Tags for this Post

agency for persons with disabilities, developmental disabilities, litigation, medicaid, waiver,

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