Reversing a lower court decision, the Sixth Circuit Court of Appeals holds that assisted living residents applying for Medicaid benefits are not entitled to retroactive benefits. Price v. Medicaid Director (6th Cir., No. 15-4066, Sept. 30, 2016).
Assisted living residents Betty Hilleger and Geraldine A. Saunders applied for a Medicaid assisted living waiver from the state of Ohio to pay for home health care. The state found them eligible for benefits, but it denied them retroactive benefits because the state provides only prospective coverage from the date the applicant is enrolled in the waiver program.
Ms. Hilleger and Ms. Saunders filed a class action lawsuit against the state, arguing that Ohio is violating federal law by providing only prospective assisted living waiver benefits. Federal law requires that retroactive benefits be provided during the three months before the application if the applicant was eligible for benefits during that time. The state argued that eligibility for assisted living waiver benefits is prospective only because it requires, among other things, a face-to-face assessment of the applicant and that because an individual cannot be eligible for benefits prior to the face-to-face assessment, individuals cannot be enrolled retroactively in the waiver program. The U.S. district court granted summary judgment to the class, and the state appealed.
The U.S. Court of Appeals for the Sixth Circuit reverses, holding that the assisted living residents were not entitled to retroactive benefits. According to the court, Ms. Hilleger and Ms. Saunders were ineligible for Medicaid assisted-living benefits until the state approved their service plan. Therefore, the state "complied with federal law, rather than violated it, when it declined to use Medicaid funds to pay for assisted-living services that were provided before [the state] approved a plan of care for the recipient of those services."
For the full text of this decision, go to: https://www.opn.ca6.uscourts.gov/opinions.pdf/16a0245p-06.pdf
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