Moore v. Medows

Court Rules Georgia Medicaid Agency Must Provide Prescribed Services to Child

A 12-year-old girl from Madison County has won a significant victory in a federal lawsuit against Dr. Rhonda Medows, Commissioner of the Georgia Department of Community Health, the state’s Medicaid agency. On June 9, U.S. District Court Judge Thomas W. Thrash rejected the Department of Community Health’s claim that it had the discretion to refuse to provide healthcare that had been prescribed by the girl’s treating physician.
The child, known as “Callie” to her friends and family, has many complex medical conditions that require nursing care. Callie is eligible for Medicaid and receives some Medicaid-funded nursing services in her home. Her doctor prescribed 94 hours of private duty nursing care for her, but the Department of Community Health approved only 84 hours of this service.
The Georgia Advocacy Office filed suit on Callie’s behalf to enforce her rights under the Early and Periodic Screening, Diagnostic and Treatment services (“EPSDT”) provisions of the Medicaid Act [42 U.S.C. §1396d(r)]. EPSDT requires states participating in Medicaid to ensure that Medicaid-eligible children under age 21 receive all of the health care services and treatments that their treating physicians determine to be necessary to “correct or ameliorate” any physical or mental illness or condition.
In ruling in Callie’s favor, the federal district court found that states participating in the Medicaid program do not have the discretion to deny funding for treatments and services listed in the Act when prescribed by a treating physician for a Medicaid-eligible child.
Joshua Norris, the director of legal advocacy at the Georgia Advocacy Office, said the decision has implications for the more than 700,000 children in Georgia who are eligible for Medicaid.
“The court is simply making Georgia comply with Congress’ intent that all children who are eligible for Medicaid actually receive the services and treatment that will help them be in the best health possible. This decision affirms that treating physicians, and not the state, should make those decisions and that Georgia’s Medicaid agency must provide children eligible for Medicaid
what the doctors have prescribed for them.”