GOSH! What happened to our appeal rights?! : how NC DHHS screwed Medicaid consumers of their mental health appeal rights

Bring on the attorneys.....

Here's the lowdown on what has taken place re: Medicaid appeals as associated with the cutting of services by NC DHHS:
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I have a client who has been receiving 3.5 hours/ week of Community Support Service (12 hours/ week/ max/ client is what NC DHHS states it will cover; I did not offer the CSS; I did a psychological assessment on him; he is a dually eligible client e.g., both Medicaid and Medicare; all CSS comes via Medicaid).

He had a head injury and thus his diagnosis is Cognitive Disorder NOS, the 'head injury' diagnosis. Yes, head injured people can learn new skills in order to circumvent head injury difficulties and you would be surprised at the level of head injuries amongst the indigent population.

The purpose of CSS is associated with 'rehabilitation' and the learning of new skills as associated w/ that 'rehabilitation.'

NC DHHS via Value Options, the authorizing agent for NC DHHS and by default, Western Highlands Network (WHN) LME, lowered his CSS available hours to 1.5 hours/ week from 3.5 hours/ week.

This is hardly enough for a company to even bother with the matter, given the cost of gasoline re: seeing the client who has no transportation----and most Medicaid clients have no transportation and there is little public transporation outside of Asheville in western NC.

This is what the Value Options letter stated to the Endorsed Provider company representative (the client has not received his letter). I am posting the pertinent information from the Value Options letter to the representative of the Endorsed Provider company who has been doing CSS work w/ the client:

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Value Options letterhead: 'Improving Behavior to Improve Health'

"Informal appeals are decided by a hearing officer at DHHS....

How to file a formal appeal:

Formal appeals are before a judge from the Office of Administrative Hearings (NOTE THE DIFFERENCE FROM HEARING OFFICER AT DHHS: see below for importance of this matter)

An administrative law judge will make a decision in your case. The agency then reviews that decision. Further appeal to court is allowed after the agency decision. ....

If you appeal and remain otherwise Medicaid eligible for the service, Medicaid will continue to pay for the services you now receive until the final agency decision, unless you give up that right. IF YOU LOSE YOUR FORMAL APPEAL, YOU MAY BE REQUIRED TO PAY FOR THE SERVICES THAT CONTINUE BECAUSE OF THE APPEAL.

lET'S SAY IT AGAIN, SAM: If you lost your formal appeal, you may be reequired to pay for the services that continue because of the appeal...."

So, the client is left believing that the Endorsed Provider company may sue them (ridiculous to sue a Medicaid client; they don't have anything) and so the client relinquishes the CSS as s/he believes the Endorsed Provider company----who basically EATS THE COST of providing the service, if they be so naive, will turn around to gig the client.

Check. And mate.

The Endorsed Provider company will not provide the service as they figure they will eat the cost and the client relinquishes the CSS as they do not want to be sued by the Endorsed Provider company who has eaten the cost.

Fun's only beginning.

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Background information necessary for understanding what is taking place here:

Recipients of Medicaid services receive a 'MAINTENANCE OF SERVICES' unless---unless---unless----they move from an Informal Appeals Process and into a Formal Appeals Process before a judge.

If a Medicaid client moves through the below enumerated Level One of the appeals process----which appears at this time to be the only process which is still in place----though in a phantom-manner-----given that the Level Two appeals process, specifically, Office of Administrative Hearing, and Level Three appeals process, specifically, the Clinical Policy & Program Section of NC Medicaid tell one to go back to the original DHHS Hearing Office----and IF- IF- IF the NC DHHS Hearing Office, the Level One appeal process 'cannot mediate the appeal' (per Lavette Young of the NC DHHS Hearing Office), then the appeal process goes before a judge at which time the Medicaid recipient loses rights associated with a 'Maintenance of Service'---because NOW the informal appeal process has become a FORMAL appeal process.

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LEVEL ONE APPEAL PROCESS for denied Medicaid services:

Through September 30, 2008, the NC DHHS Hearing Office (919 647 8200) was 'officially' attending to the Medicaid appeals, specific to Recipient Appeals (there are also provider appeals but that is not what we are talking about here).

When 919 647 8200 was called, we were told to call the next level of appeal:

LEVEL TWO APPEAL PROCESS for denied Medicaid services:

This first week of October, 2008, SUBSEQUENT TO SEPTEMBER 30, 2008, the next tier of appeals, specifically, THE OFFICE OF ADMINISTRATIVE HEARING (919 431 3000) was 'supposed' to be doing appeals according to the NC DHHS Hearing Office. When this office was called the first week of October, 2008, the person stated: "We're not doing Medicaid appeals yet. Try calling this number for the Clinical Policy and Program Section of NC Medicaid: tel 919 855 4260.'

lEVEL THREE APPEAL PROCESS for denied Medicaid services:

'Jane' at this office of Clinical Policy & Program Section of NC Medicaid, told us to call 'Laura Brown' within the same office We called her: no answer and no return call. Then someone at the switchboard for Clinical Policy & Program Section of NC Medicaid sent us back to the beginning, specifically, to LEVEL ONE APPEAL PROCESS for denied Medicaid services.


BACK TO LEVEL ONE APPEAL PROCESS WITH AN ADDITIONAL CAVEAT: If no mediation can resolve the matter, THEN the Medicaid consumer move from an Informal Appeal Process to a Formal Appeal Process---at which point s/he loses their rights to Maintenance of Service.