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Medicaid Advocates Successfully Use Medicaid Exception Requests and Requests for Memoranda of Understanding to Meet Clients’ Urgent and Unmet Needs

MPLP Winter 2008 Elder Law Section Newsletter Article

                Issue 35, Winter 2008

Medicaid Advocates Successfully Use Medicaid Exception Requests and Requests for Memoranda of Understanding  to Meet Clients’ Urgent and Unmet Needs

 

Medicaid client advocates have found a sympathetic ear in State Medicaid Director Paul Reinhart.  Director Reinhart has been willing to grant numerous exception requests for clients who would not otherwise have received services and to enter into memoranda of understanding with nursing homes and MiChoice providers who serve particularly expensive clients.  Examples of exceptions that have been granted include:


·                 A 700 pound client remained confined to bed for months because he does not have a special lift to transfer him from his bed to his motorized wheelchair.  Although Medicare is supposed to provide coverage for this durable medical equipment, advocates’ persistent effort to obtain the lift had failed because DME providers were skeptical they would receive adequate Medicare  reimbursement for this costly equipment. Litigation on the matter would have taken many months and may not have been successful.  As the result of a request for help, Director Reinhart directed his staff to grant prior authorization for the lift and for a special scale that will assist the client in his weight reduction efforts.   Medicaid staff worked diligently with DME providers to locate an appropriate apparatus and the client should soon enjoy both the physical and psychological benefits of being out of bed for the first time since May.

 

·                 A client with urgent health care needs who returned to the state was refused admission by more than 150 Michigan nursing homes because of his heavy care needs.  He was granted an exception so that he could be immediately admitted to the MiChoice program.

 

·                 Clients who have been in a nursing home for less than six months and wish to transition into the MiChoice  program and clients who are in the community at imminent risk of nursing home placement have frequently  been granted exceptions so that they can be immediately admitted to the MiChoice program with appropriate funding.

 

·                 An extremely fragile heavy care recipient with challenging behaviors had been involuntarily discharged from a multitude of facilities.  No other facility was initially willing to admit him.  Advocates  obtained a memorandum of understanding to provide substantially increased funding to one of the few facilities in the state that was equipped to care for him and educated the facility about the availability of additional funding for other applicants whose care needs were extremely expensive. 

 

Advocates have also had some success in working with the Medicaid policy staff to obtain hardship waivers for Medicaid applicants who have been unable to provide adequate financial or other documentation.  One advocate is now requesting an exception for payment of medications that are not provided pursuant to Medicaid policy but that are medically necessary for a client.  Other advocates are encouraged to be creative and assertive in seeking exceptions, memoranda of understanding, and hardship waivers in urgent and difficult cases and are likely to find Medicaid policy staff more receptive to requests for help than DHS caseworkers.

 




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