HARTFORD (CN) – Connecticut has so “systematically stripped” workers from its Department of Social Services that the state can no longer “process Medicaid applications in a timely manner,” delaying or denying medical aid to nearly 5,000 people, according to a federal class action.
Lead plaintiff Paul Shafer says he is “one of nearly 5,000 Connecticut residents whose applications for Medicaid have been pending well beyond the 45-day time period generally required for the processing of Medicaid applications. At the end of November 2011, nearly 55 percent of all of the Medicaid applications were pending beyond the federally mandated time limits. As a result of the defendant’s failure or refusal to process Medicaid applications in a timely manner, he has been unable to access Medicaid coverage for his anti-seizure medication or other medically necessary treatment for his seizure disorder.”
Class representatives Shafer and Joshua Harder sued Connecticut Department of Social Services Commissioner Roderick Bremby.
Harder says he is “one of the thousands of individuals whose applications for Medicaid have been approved, subject to a designated ‘spend-down’ requirement. Every month, several hundred such ‘medically needy’ individuals are newly found to be eligible for Medicaid subject to this requirement. Although plaintiff Harder provided documentation in October 2011, in the form of medical bills, of compliance with his ‘spend-down’ requirement for the six month period between July 1 to December 2011, he was not provided Medicaid benefits. As a result of the defendant’s failure or refusal to provide Medicaid benefits in a timely manner to persons who have demonstrated compliance with their respective ‘spend-down’ requirements, Plaintiff Joshua Harder has been unable to access Medicaid coverage for his needed medical treatment. Neither of the named plaintiffs has received timely or adequate notice of a reason for the delay in the processing or the receipt of their Medicaid benefits.”
Under the Medicaid spend-down requirement (42 C.F.R. 435.831(d)), “‘medically needy’ individuals receive a notice from DSS every six months advising them that they are eligible for Medicaid once they satisfy the designated spend-down amount for that period, an amount which is equal to the amount by which their income exceeds the medically needy income limit in their part of the state plus any applicable disregard, multiplied by six,” the complaint states.
“The notices advise these ‘medically needy’ individuals that their Medicaid benefits will be activated upon the submission of any medical bills for the current six month period, or any unpaid medical bills from a previous period, meeting or exceeding their particular spend-down amount, and that, upon such submission, they will be eligible for full Medicaid benefits until the end of that six month period, at which point a new spend-down period will begin with potentially a different spend-down amount.
“In response to these notices, ‘medically needy’ recipients routinely present medical bills to demonstrate satisfaction of their spend-down amounts.
“The same DSS eligibility workers who process Medicaid applications commonly process medical bills submitted in an attempt to satisfy spend-down amounts.
“Because of their high caseloads, these workers are not able to timely process these medical bills to determine that spend-down amounts have been satisfied, resulting in eligible recipients waiting weeks or months for the calculation to be completed and Medicaid benefits to be provided.
“Sometimes, the processing of medical bills submitted to establish satisfaction of Medicaid spend-downs is so untimely that the end of the six month spend-down period arrives before the DSS worker has been able to review the medical bills submitted.”
The complaint was filed by two attorneys with New Haven Legal Assistance.
A spokesman for the Connecticut Department of Social Services said that filing a lawsuit was not the best way to handle the situation.
“We are disappointed that legal services has chosen to file a lawsuit that will consume precious time and resources, rather than working with us on practical approaches to re-investing in DSS,” David Dearborn said in a statement.
“It’s common knowledge that the agency has dealt with major, double-digit percentage staffing losses over the last decade and increasing monthly Medicaid (19.5%) and SNAP (81.0%) caseloads over the past five years. To meet these critical needs, we are working with the Office of Policy and Management to refill existing vacancies and hire additional staff; and we have begun the process of upgrading the entire IT infrastructure.”
Legal Assistance attorney Shelley White replied: “We realize of course that the state has had budgetary problems. But even under these circumstances, states must comply with federal law if they want to continue to receive hundreds of millions of dollars of federal reimbursement under Medicaid. One of the most basic requirements of federal law is that applications for Medicaid must be processed timely, in a specified number of days, so that Medicaid is actually available when needed.”
White’s co-counsel Sheldon Toubman added that “previous administrations seemed to not value the essential benefit programs administered by DSS and thus severely cut back on its staffing in successive budgets. It is unfortunate that Governor Malloy’s Administration and his Commissioner of Social Services inherited such a severely hobbled agency.
“However, given his commitment to preserving the safety net, we are optimistic that Governor Malloy will step up to the plate and recognize the need to reverse these cutbacks and thus avoid jeopardizing federal funds.”
DSS spokesman Dearborn countered: “As Commissioner Rod Bremby has emphasized, we can’t correct and resolve issues resulting from lack of investment over the past decade in a matter of months. However, the commissioner and agency are committed to doing so as promptly and as cost-effectively as possible.”
Toubman bristled at the notion that the lawsuit would tie up resources, saying this has been an issue for years.
As for the IT system, he said the earliest those improvements will be made is 16 months from now.
“How does that help someone today can’t get onto Medicaid?” Toubman asked in a telephone interview.
He said what the state needs now is more staff. He suggested that many workers retired last October and could be hired back
Plaintiffs seek declaratory and injunctive relief, enjoining the state from failing or refusing to process applications for Medicaid and failing to provide Medicaid benefits to eligible people within the time frames required by federal law.