AARP Foundation attorneys entered their appearance in a case urging a federal court to require the State of Tennessee to live up to its agreements. As part of an earlier lawsuit, the state had agreed to ensure that medically necessary services and pharmaceutical drugs were provided to Medicaid beneficiaries.
Medicaid is a federal-state partnership that provides health care services to people whom Congress has determined are particularly at risk — older Americans and other residents of long term care facilities, people with disabilities, the poor, and children in specific situations (low income, in foster care, etc.). Before the federal Medicaid Act, low-income uninsured people obtained health services unevenly if at all. The Medicaid Act was intended to remedy a growing public health problem by providing a uniform and statewide medical insurance program while allowing states to experiment with innovative health care delivery approaches. The U.S. Supreme Court confirmed decades ago that Medicaid is an "entitlement program," meaning that individuals who meet the eligibility criteria have a right to services, and meaning that access to the programs and safeguards for appealing determinations of ineligibility are protected by the U.S. Constitution.
Those safeguards were at issue in a Tennessee lawsuit of Grier v. Goetz several years ago, a suit settled in 2003 when the state agreed, among other things, to more carefully consider the appeals of beneficiaries whose claims for treatment were denied coverage under its Medicaid program (a program known as TennCare). The consent decree entered into by the state also contained specific safeguards to protect TennCare beneficiaries' access to prescription drugs.
The State of Tennessee requested permission to modify that consent decree. The state argued for a change in the appeals process when a claim is denied (specifically seeking to redefine what is "medically necessary"), and to limit prescription drugs to no more than five prescriptions a month with no more than two name brand prescriptions. Courts allow modification of consent decrees if there have been significant changes in circumstances or if enforcing the decree as written would be against the public interest.
The District Court denied the bulk of the changes sought by the state. Plaintiffs' attorneys thereafter were awarded fees to be paid by the defendant. This fee award was appealed to the 6th circuit by the state. The case continues over the award of fees.
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