Fighting for Access to Medicaid Services for Adults

DRP has brought many cases to enforce Medicaid rights for adults with disabilities in Pennsylvania.  DRP has filed lawsuits to ensure that the managed care organizations (MCOs) with which Pennsylvania contracts to provide Medicaid comply with the federal Medicaid statute.  In Metts v. Houston (1997), DRP represented a class of Medicaid-eligible individuals to ensure that their services were not unlawfully denied, reduced. or terminated by their HealthChoices Medicaid managed care organizations (MCOs).  The parties reached a settlement that included requirements that:  barred the MCOs from denying, reducing, or terminating home health services on the basis that the individual’s condition is chronic, developmental, long-term, or stable or because they do not have any particular diagnosis or condition; required the MCOs to use non-conflicted case managers; and provided guidelines for motorized wheelchairs and incontinence products.    In Bokoski v. Houstoun (1999), DRP asserted that Pennsylvania violated the federal Medicaid law by failing to ensure that the MCOs authorize medically necessary motorized wheelchairs.  Pennsylvania agreed to issue new standards to ensure appropriate evaluations for the need for wheelchairs.

DRP has fought for access to Medicaid Waiver services in many cases.  A Medicaid Waiver is a program that provides access to HCBS which allows a person to remain in their home and community.  In St. John v. DHS (2014), we were able to secure services for two clients with Autism in the OBRA Waiver.  In Kline v. DHS (2015), DRP brought a case on behalf of a group of individuals with Autism with co-occurring mental illness who were stuck either in jail or state hospitals without services. We were able to successfully obtain services in the Adult Autism Waiver for these individuals.  In Miller v. DHS (2016), we represented clients in the Consolidated Waiver, the largest waiver for individuals with intellectual disability, to ensure they had access to the Waiver services that they needed to stay in the community and avoid institutionalization, such as residential rehabilitation and nursing.   In Leonard v. Mackereth (2014), we filed suit on behalf of a group of individuals with Autism whose waiver services were in jeopardy.  Those individuals sought to enforce their entitlement to Medicaid services under the state plan, and in settlement, we were able to ensure that they would continue to be served in their HCBS Waiver program.

DRP has also worked to enforce the Preadmission Screening and Resident Review (PASRR) requirements of the Medicaid statute which aim to ensure that individuals with intellectual and other developmental disabilities (I/DD)and individuals with mental illness are not placed inappropriately in nursing facilities and that those with I/DD and mental illness who are in nursing facilities have access to “specialized services” and, in some cases, community placement.  DRP filed a class action, Richardson v. Snider, in 1992 to challenge the state’s failure to fully implement PASRR.  Richardson resulted in a settlement that resulted in a comprehensive process to ensure PASRR implementation, including access to specialized services and community services.