Court: Service plan required for assisted living benefits under Medicaid

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The state of Ohio will not be required to pay retroactively for benefits that Medicaid-eligible assisted living residents received before their written service plans were approved by the state, the U.S. Court of Appeals for the Sixth Circuit ruled on Friday.

The federal appeals court decision sets a precedent that also covers Michigan, Kentucky and Tennessee and reverses a district court ruling that Medicaid beneficiaries could apply for retroactive benefits if they could prove that they were eligible for the benefits at any time in the three months before they applied.

The appeals court said that the Medicaid Act and the Buckeye State's Medicaid regulations required that a written service plan be in place before a resident is eligible for benefits.

The Ohio Centers for Assisted Living, the state affiliate of the National Center for Assisted Living, filed a friend of the court brief supporting the plaintiffs. “They contend that submission of an application to the Ohio Department of Job and Family Services for assisted living benefits constitutes an application for Medicaid, and that it is therefore impossible to obtain pre-application approval of a service plan,” court documents state. OCAL, however, “neglects to address the regulatory provision that allows seniors to receive an 'in-person [eligibility] assessment' from the local passport agency before making an application with the Department of Job and Family Services,” the court said.

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