A Georgia federal court has disapproved an attempt by the state Medicaid agency to reduce the private duty skilled nursing services provided to a severely disabled child from 94 to 84 hours per week. The court ordered the agency to provide the 94 hours of services that her treating physician had prescribed.
EPSDT program
The child suffered from severe brain damage caused by a stroke in utero. At 12 years old she was completely dependent on others to meet every need and required constant monitoring and care. She began receiving assistance at three years of age through a special program for "medically fragile" children under the early and periodic screening, diagnosis and treatment (EPSDT) benefit.
All states that participate in Medicaid must provide EPSDT services to eligible children. In addition to well-baby and well-child examinations, screenings and immunizations, Soc. Sec. Act §1905(r)(5) directs states to provide any "necessary health care, diagnostic services, treatment, and other measures … to correct or ameliorate defects and physical and mental illnesses and conditions …, whether or not such services are covered under the State plan.". The Georgia agency agreed that it was obligated to provide private duty nursing services for the child but contended that it had discretion to determine the number of hours it would provide.
The court rejected the agency's view that its action, apparently a cost-cutting measure, was within its discretion. The court noted that the language of the statute leaves the agency no discretion whatsoever. If federal Medicaid law allows a state to provide a service, and the treating professionals determine that the service is medically necessary, the state may not deny or limit coverage for any reason other than medical necessity.
Source: Moore v. Medows, N.D. Ga., June 4, 2008.
For more information on this and related topics, consult the CCH® Medicare and Medicaid Guide.
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