Legal Advocacy
Maryland Court Protects Against Unwanted Institutionalization
AARP Successfully Fights Maryland’s Overly Restrictive Medicaid Eligibility Standard
AARP Foundation Litigation attorneys along with Maryland’s Legal Aid Bureau represent a Maryland woman fighting to avoid institutionalization and instead obtain home and community based services. Ruling in Maryland Department of Health and Mental Hygiene v. Ida Brown, the Maryland Court of Appeals (the state’s highest court) agreed with a lower court that the state used the wrong standard in assessing her eligibility for home and community based care, and that the Administrative Law Judge (ALJ) hearing her appeal of denial of benefits did not allow Ms. Brown to present critical evidence during her appeal.
The dispute
Ida Brown is in her mid-eighties and has several serious medical conditions, including Alzheimer’s dementia, osteoarthritis, osteoporosis, hypertension, and cataracts. She has suffered several falls, has memory loss, is unable to administer her own medications, and when not supervised has wandered away. She applied to her state Medicaid program for a community based waiver, which would allow her to obtain supervisory services in her home or in an assisted living facility but avoid institutionalization in a nursing home. However, she was denied because the Department of Health and Mental Hygiene determined that she did not require 24 hour supervision by licensed health care professionals, which is equivalent to a skilled level of care.
Medicaid is a federal-state partnership that provides health care services to people whom Congress has determined are particularly at risk. The program provides health insurance to four distinct population groups: older persons and other residents of long term care facilities, people with disabilities, the poor, and children in specific situations (low-income, in foster care, etc.). Medicaid is intended to foster innovation among the states but ensure a basic level of care for all statutorily-eligible persons, federal law sets the ground rules and requirements for programs, beneath which states cannot slip.
States can apply for “Older Adult Waivers” that allow home- and community-based services that are more extensive than room and board but less intensive then those provided in institutions. Older Adult Waivers allow older adults who have some need for supervision or care but who want to avoid the intrusion and restrictions of institutionalization to have an option that allows them to remain in their homes or in assisted living situations.
Maryland received federal approval for its Older Adult Waiver program, which is implemented pursuant to legislation enacted by the state legislature, and it is that statute and its implementation that were at issue in the case. According to the statute, a beneficiary is eligible for a waiver if he or she needs health related care and services above the level of room and board and care for at least 5 out of every 7 days because of mental, physical, functional or cognitive conditions. The state legislation explicitly defines “health related” care as something that does not rise to the level of medical, nursing, or other care that requires the attention of a licensed medical professional – it allows a much lower standard of health care to suffice.
However, the state agency responsible for implementing Medicaid argues that waiver eligibility should be determined under a state regulation which essentially requires applicants to need skilled care. At an eligibility hearing the ALJ refused to consider evidence of Ms. Brown’s medical condition which would have helped establish her eligibility but which was not presented to the Department with her application for benefits.
The lawsuit
Arguments filed by her attorneys with the court meticulously detail the letter of both state and federal law and the intent of the legislature as reflected in legislative debates. In particular, the brief noted, it is significant that the legislature’s enabling statute was enacted at a time that Maryland ranked near the bottom of all states’ Medicaid programs in terms of long-term care systems – a standing the legislature deliberately sought to change.
As for evidence of her eligibility, Ms. Brown argued that ignoring her declining health conditions runs afoul of the language of a federal Medicaid statute, and federal and state caselaw that directs an ALJ to accept new evidence up to the date of an eligibility hearing.
Both a lower court and an appeals court agreed, rulings now affirmed and adopted by the state’s highest court. Ruling first that the agency had misread the underlying state Medicaid law, the court found that the law outlined eligibility criteria that did not limit beneficiary eligibility as narrowly as the agency did – but even if it did, that reading was unlawfully more restrictive than the federal statute. The court also agreed with Ms. Brown that the ALJ erred in not allowing the plaintiff to bring forward all her evidence including a later medical report. Emphasizing that the law requires a full evidentiary hearing at the administrative appeal level.
AARP’s attorneys’ participation in this case follows their participation in other cases that have challenged determinations by and procedures followed by the Maryland Department of Health and Mental Hygiene. The lawsuits are important because many eligible applicants are being denied benefits and because of a lengthy waiting list they may never receive much needed HCBS services. Today’s ruling has profound implications for Maryland residents and well help guide other courts considering the issue.
Contact persons:
Bruce Vignery
bvignery@aarp.org
Sarah L. Lock
slock@aarp.org
(202) 434-2060
November 7, 2008