Tuesday, March 29, 2005

Aged and Disabled Medicaid Waiver class action settles

Cyrus et al v. Nusbaum, case number 3:04cv00892 in U.S. District Court in Huntington, has settled. The case presented due process challenges to the initial medical eligibility and periodic re-evaluation processes beneficiaries must go through to receive home and community-based care under the waiver. Early in the litigation the court had issued a temporary restraining order requiring the state to reinstate services for beneficiaries who had been terminated following re-evaluations done since November 2003 (when WVMI's contract to complete the PAS 2000 forms became effective).

The settlement provides for several improvements in evaluation, re-evaluation, and notice of denial. Specifically:

  • regular annual re-evaluations must include input from the beneficiary's treating physician

  • home visits require at least 2 weeks advance notice

  • though nurses can still fill out the PAS they cannot make medical diagnoses, diagnostic information must come from a physician

  • more complete information must be provided with denials of medical eligibility, including a copy of the PAS and explanation of denial including discussion of the deficits and relevant medical standards

  • before final denial can be issued there will be notice of a Potential Denial including the information above and providing a two-week opportunity for the beneficiary to submit supplemental information to be considered

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