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Medicaid Beneficiaries Challenge Washington D.C.'s Denials Process

AARP’s brief supports Medicaid beneficiaries who challenge the District’s failure to provide written notice of a denied claim for prescription medications.

Background

AARP joined a friend-of-the-court brief supporting Medicaid beneficiaries in the District of Columbia denied prescription drugs without any notice of the reasons for denials.

Medicaid is a program that pays for health care services for the neediest of our citizens. It is jointly funded by federal and state governments to reimburse providers (including doctors and pharmacies) who provide direct services to eligible enrollees. States develop reimbursement plans and policies, which the federal government must approve, and which must meet certain specified federal minimum standards, including the right of beneficiaries to receive written notice when a claim is denied that explains the reasons for the denial.

In D.C., the District’s decisions about coverage of pharmaceutical drugs are communicated electronically between the D.C. government and pharmacies. D.C. does not require pharmacies to communicate a reason for denial to the Medicaid beneficiary and the pharmacies often do not. Beneficiaries receive no written notice for denial of prescription drugs, leaving them with two untenable options: (1) pay for the prescriptions themselves or (2) forego the prescribed medication altogether.

Beneficiaries filed a class action lawsuit, alleging violations of state and federal Medicaid law as well as violation of the due process clause of the U.S. Constitution. A federal district court dismissed the suit, but an appeals court reversed that decision. Bounced down to district court again, the court once more dismissed the suit; that decision is now on appeal to the U.S. Court of Appeals for the D.C. Circuit.

AARP Foundation Litigation attorneys joined other attorneys at the National Health Law Program and the private law firm of Terris, Pravlik & Millian, LLP, to file a friend-of-the-court brief on behalf of beneficiaries. The brief explains the federal law, the scope of the state’s obligation to provide written notice, and the harm to Medicaid enrollees when coverage is denied without explanation or information about the opportunity to appeal.

What’s at Stake

Courts have repeatedly affirmed the fundamental constitutional right of Medicaid beneficiaries to receive written denial of services that explains the reasons for the denial and the beneficiary’s appeal rights. Medicaid services are denied for a host of reasons, some of which are based on an easily-corrected technicality or error. Medicaid serves the neediest of our populations who, without adequate notice of a denial of services and an opportunity to appeal the denial, will usually go without the services altogether.

Case Status

N.B. v. District of Columbia is before the U.S. Court of Appeals for the D.C. Circuit.