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Does an individual seeking Medicaid have a right to a prompt eligibility determination? The answer is "yes," and that right is one that can be enforced through the Courts.
Sue Doe, an individual with developmental disabilities sued the South Carolina Department of Disabilities and Special Needs and the South Carolina Department of Health and Human Services after they delayed determining her Medicaid eligibility status. On appeal, Doe sought attorney's fees under Section 1983 due to the Department's failure to determine her eligibility with reasonable promptness. 42 U.S.C. § 1396a(8) provides that a State Medicaid plan must provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals. Months after submitting her application, the State had not determined whether she was eligible. The State's failure to make a determination left her in limbo, without access to the care and services she claimed she needed.
Initially the Department argued the case was moot on appeal because the State began to provide some services for Doe. The State began providing some respite care; the services Doe had requested were residential habilitation. The Court found that the case was "live" and that Doe did not "lack a cognizable interest in the outcome" because the Department, by its own admission, had not provided her with requested residential habilitation services, had not made a determination on the services requested and because the services being provided would only be provided "until her true status [was] determined." Thus, Doe's claim that her eligibility must be determined with reasonable promptness was a live claim and she continued to have an interest in the outcome.
After determining Doe still had an interest in the outcome, the Court went on to consider whether she could enforce her right to a prompt eligibility determination. Examining prior case law, the Court found that she could.
Applying the Blessing test to the reasonable promptness provision found in § 1396a(a)(8), we conclude that the provision gives rise to a right enforceable under § 1983. First, the provision is expressly intended to benefit "all" individuals eligible for Medicaid assistance, a group that, the parties do not dispute, includes Doe. See § 1396a(a)(8). Second, the provision is not so "vague and amorphous" that the judiciary cannot competently enforce it: the provision is clear
that the standard for informing applicants of their eligibility for Medicaid services is "reasonable promptness" and the relevant federal and state regulations and manuals define reasonable promptness as fortyfive days or ninety days, depending on the applicant. See, e.g., 42 C.F.R. § 435.911; South Carolina Medicaid Manual, cited at J.A. 242;
United States Department of Health & Human Services Center for Medicaid and State Operations, Olmstead Update No: 4, at J.A. 290. Third, the provision uses mandatory rather than precatory terms: it states that plans "must" provide for assistance that "shall" be delivered with reasonable promptness. See § 1396a(a)(8).
Finally, the Medicaid Act does not explicitly forbid recourse to § 1983. Wilder, 496 U.S. at 521. Nor does the Act impliedly forbid such recourse: although the Act provides that states should adopt a fair hearing process, the Act does not contain a "comprehensive enforcement scheme that is incompatible with individual enforcement
under § 1983." Blessing, 520 U.S. at 341 (emphases added)
Having determined that the claim was neither moot nor waived, the Court of Appeals vacated the district court’s dismissal of her claim and remanded for further proceedings.
Doe v. Kidd, United States Court of Appeals for the Fourth Circuit, Case No. 05-1570 (September 19, 2007).
Opinion at: http://pacer.ca4.uscourts.gov/opinion.pdf/051570.P.pdf.
Petition for Petition for Rehearing and Rehearing En Banc denied October 16, 2007.
What this case tells us is that the State cannot force an individual to wait indefinately for necessary medical assistance. They must either approve or deny the Medicaid application. The reason States delay is because a denial triggers a right of appeal; thus, withholding a determination allows the State to improperly deny an applicant access to necessary medical care. Under Doe, if the State improperly delays is decision, not only can the decision be forced in court but the State may be forced to pay the applicant's attorney's fees associated with the litigation.
Notes:
Federal Regulation requiring timely determination: 42 C.F.R. § 435.911
Georgia Code: O.C.G.A. § 49-4-13(a) provides:
Except as provided in subsection (b) of this Code section, an applicant for or recipient of public assistance who is aggrieved by the action or inaction of the department, including any county department of family and children services, shall be entitled to a hearing. Each applicant or recipient shall be notified of his or her right to a hearing. Upon request for such hearing, reasonable notice of the time and place thereof shall be given to such applicant or recipient. Such hearing shall be conducted by the Office of State Administrative Hearings in accordance with Chapter 13 of Title 50, the 'Georgia Administrative Procedure Act,' the rules and regulations of the Office of State Administrative Hearings, and the rules and regulations prescribed by the board. The decision of the commissioner on any appeal shall be final, subject to the right to judicial review of contested cases under Chapter 13 of Title 50.
Georgia is in the Eleventh Circuit. In Doe by & Through Doe v. Chiles, 136 F.3d 709, 714 (11th Cir. 1998), the Eleventh Circuit summarized the "timeliness" rules as follows:
Section 1396a(a)(8) reads: "A State plan for medical assistance must ... provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible individuals." 42 U.S.C.A. § 1396a(a)(8) (West Supp.1997) (emphasis added - where?). A corresponding regulation provides that the responsible state agency "must," among other things, "furnish Medicaid promptly to recipients without any delay caused by the agency's administrative procedures," and "continue to furnish Medicaid regularly to all eligible individuals until they are found to be ineligible." 42 C.F.R. § 435.930(a)-(b) (1996). Another regulation states that "the agency must establish time standards for determining eligibility and inform the applicant of what they are." 42 C.F.R. § 435.911(a) (1996). These periods are not to exceed "ninety days for applicants who apply for Medicaid on the basis of disability" or "forty-five days for all other applicants." 42 C.F.R. § 435.911(a)(1)-(2) (1996). Moreover, the agency "must not use the time standards" as "a waiting period." 42 C.F.R. § 435.911(e)(1) (1996). It is this panel's task to determine whether the "reasonable promptness" clause of section 1396a(a)(8) "gives rise to a federal right."
After considerable review of the federal statutory and regulatory scheme surrounding Medicaid, the Eleventh Circuit concluded: "that the appellees have a federal right to reasonably prompt provision of assistance under section 1396a(a)(8) of the Medicaid Act, and that this right is enforceable under section 1983."
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