Maryland Appeals Court Ruling Could Broaden Medicaid Eligibility Standards For Elder Care; Audits Show New York Medicaid Overpaid Service Providers By

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Maryland
The Maryland Court of Special Appeals last month ruled that some Medicaid eligibility standards used by the Department of Health and Mental Hygiene were stricter than federal laws allow, and advocates hope the broad standards outlined in the case will be applied universally, the Baltimore Sun reports. The lawsuit was filed by Diane Byus on behalf of her mother, Ida Brown, after Brown was diagnosed with Alzheimer's disease and was unable to receive assistance through the Older Adults Waiver Program, a Medicaid program designed to provide services such as nursing and adult day care.

Maryland limits eligibility in the program to residents older than age 50 who have incomes less than $1,869 a month and require daily care from licensed health care professionals. Although Brown, who also has several chronic conditions, requires daily monitoring, she does not require constant care from a physician or nurse, the Sun reports. Attorneys from the Legal Aid Bureau and AARP argued in the case that state and federal laws limit eligibility to residents who regularly require "health-related care and services," such as those that could be provided in a nursing home, but not necessarily daily by a skilled nurse.

The state health department has not indicated whether it would appeal the decision. State officials said that loosening eligibility requirements for the program would allow more people to receive benefits and could lead to denial of care for some of the neediest residents because of limited funding. The program costs the state about $81 million annually.

Legal Aid attorneys are working on several similar cases. According to the Sun, lawsuits were filed against at least two other states that tried to limit community- and home-based care services programs. Advocates in Kentucky succeeded in overturning restrictions, while Oregon's restrictions were allowed to stand (Green, Baltimore Sun, 12/10).

New York
Two audits released on Monday by New York State Comptroller Thomas DiNapoli showed that the state made $5 million in Medicaid overpayments to 135 in-home health care, outpatient and laboratory service providers across the state, Long Island Newsday reports. One of the audits, which spanned a five-year period through September 2006, showed that the state overpaid home health care providers $2.1 million for Medicaid claims of beneficiaries who were living in nursing homes. The second audit, over a five-year period ending in February 2007, showed that the state overpaid $2.9 million in Medicaid to outpatient and laboratory service providers for services that should have been paid by the facilities that ordered.

DiNapoli said, "Medicaid costs are already high," adding, "The last thing the state needs to do is pay for services not rendered or pay for the same service twice. The state should take the steps necessary to recoup these costs."

The audits said the overpayments are due to ineffective practices of the state Office of the Medicaid Inspector General and home health care providers who either ignored or misinterpreted Medicaid billing rules. The audits also noted that the state does not have a proper Medicaid claims handling system to identify cases of overpayments (Dowdy, Long Island Newsday, 12/11).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation© 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.