Have you seen?

This was part of a press release sent out recently from the Georgia Advocacy Office. I know you have already seen this, but if you haven’t, take a look and send a quick note to Josh Norris and thank him for the work of GAO.
----------------------------------------------------------------------------------
Court Rules Georgia Medicaid Agency Must Provide Child With Services Prescribed By Her Physician:
A federal district judge ruled on December 9, 2009, in Moore v. Medows, that Georgia’s Medicaid Agency, the Department of Community Health (“DCH”), must provide the nursing services to Callie Moore, a 14-year-old girl from Madison County, that her treating physician prescribed for her. The court rejected the state’s argument that it was the final arbiter of medical necessity and had the discretion to limit treatment to Callie.


Callie has many complex medical conditions that require nursing care. Callie is eligible for Medicaid and receives some Medicaid-funded nursing services in her home. Callie’s treating physician prescribed 94 hours per week of nursing care for her, but DCH would only approve 84 hours of nursing services.

The Georgia Advocacy Office (“GAO”), the designated protection and advocacy system for people with disabilities in Georgia, filed suit on Callie’s behalf in 2007 against Dr. Rhonda Medows, DCH’s Commissioner, to enforce Callie’s right 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 children under age 21 who are Medicaid-eligible receive all of the health care services and treatments necessary to “correct or ameliorate” any physical or mental illness or condition.

In ruling in Callie’s favor, the court reaffirmed Callie’s right under the EPSDT provision to all necessary care prescribed by her treating physician to treat her many complex conditions. The court ruled the state’s role was limited to reviewing a treating physician’s prescription for “fraud, abuse of the Medicaid system, and whether the prescribed service is within the reasonable standards of medical care.”

The district court had previously held that the state did not have the discretion to deny the nursing services that had been prescribed by Callie’s treating physician. The Eleventh Circuit Court of Appeals reversed that decision in an unpublished opinion finding that both the state and the treating physician have roles in determining what is necessary to “correct or ameliorate” a child’s conditions and illnesses, but leaving open the question of what those roles were. The case was then sent back to the district court.

“The court affirmed the basic right of children under the Medicaid Act to all of the care that they need to treat any condition or illness they may have, and clarified the role of the treating physician as the central figure in deciding what care is needed,” said Joshua Norris, GAO’s Director of Legal Advocacy. “The state, by contrast, does not have discretion to deny necessary care to Medicaid-eligible children, and it has a specific, limited role in reviewing the physician’s prescriptions.”