BOISE, Idaho (CN) - "Some of the most vulnerable adults in Idaho" say the state has illegally cut Medicaid assistance by 42 percent, without justification, and "will not explain why."
"The plaintiffs are some of the most vulnerable adults in Idaho," according to the federal complaint. "They live with disabling and chronic conditions such as epilepsy, muscular dystrophy, Down syndrome, schizophrenia, and developmental disabilities ranging from mild to severe. They complain to this court because the defendants (collectively referred to as the 'Idaho Department of Health and Welfare,' the 'Department,' or 'IDHW') have informed them that their Medicaid assistance will be substantially reduced for this year but will not explain why. In fact, the reasons why are 'secrets,' according to IDHW itself. The secrets are the methodologies used to calculate the amount of Medicaid resources the plaintiffs will have available for the year. As participants in the Idaho Developmental Disability Waiver program ('DD Waiver') of Medicaid in Idaho, IDHW has already determined that it is cheaper for the plaintiffs to live in home and community settings rather than in institutions. Yet, under IDHW's individual DD waiver budget setting methodology, this year the plaintiffs' individual budgets have been cut drastically - by as much as 42 percent - without explanation or any meaningful way to challenge to calculations. The secret budget setting methodology and IDHW's undisclosed revisions to it violate the Medicaid Act, state law, and the plaintiffs' rights to due process. As a result of the drastic cuts, the plaintiffs are at serious risk of institutionalization, in violation of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973."
The plaintiffs say that choices for patients with epilepsy, schizophrenia and developmental disabilities include living with family, living in a community setting or being institutionalized. Many families keep developmentally challenged loved ones at home or in a community setting, rather than institutionalized, but IDHW budget cuts may force patients into institutions, the plaintiffs say.
The Medicaid Act requires Idaho to make its budget-setting methodology "open to public inspection," but the patients say Idaho's methodology "is not open to public inspection and is not documented in administrative rulemaking or published in the Idaho Administrative Code" - that the Idaho Department of Health and Welfare considers its methodology "a trade secret."
Lead plaintiff K.W., 30, has an assessed functional age of a 15-month-old child and suffers from severe intractable epilepsy. He requires around-the-clock monitoring and assistance by trained staff. He is a participant in the DD waiver program and has chosen the self-direction option. Last year the state used its methodology to reduce his budget by more than $20,000.
"IDHW's own hearing officer ruled that the only option for K.W. were 'an adequate budget that permits him to remain in his parents' home, or institutionalization at a significantly higher cost to IDHW and a less fulfilling life for K.W. and his family,'" the complaint states.
A hearing officer reversed the state's budget cur for K.W., but cut it again this year, by 29 percent. No explanation accompanied the state's notice.
Other plaintiffs say similar things happened to them.
"Even those who appeal their individual budget reductions, contending that their budgets were calculated incorrectly, cannot learn how their budgets were calculated," according to the complaint. "They can only discover the assessor's input values to the methodology and the output - the budget amount - produced by the methodology."
The patients call the state's methodology a "black box," that is "no different than a hat from which IDHW magically pulls dollar figures."
They claim the IDHW repealed rules that entitle participants to reconsideration of their calculated budgets without telling the Centers for Medicare and Medicaid Services, which oversees state programs under the authority of the U.S. Department of Health and Human Services.
They say the state also removed a safeguard that allowed negotiation between the participant and the IDHW concerning the plan for services for each patient.
The plaintiffs want their cuts enjoined and want the stated ordered to disclose the way it calculates patient budgets, and to submit it to the Legislature for approval, as required by the Idaho Administrative Act.
They are represented by Richard Eppink with Idaho Legal Aid Services.