Ruling could result in faster Medicaid payments to supportive living providers

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Ruling could result in faster Medicaid payments to supportive living providers
Ruling could result in faster Medicaid payments to supportive living providers

A federal ruling last week may result in faster final eligibility determinations for those who apply for long-term care Medicaid benefits in Illinois — and therefore more timely payments to supportive living facilities, nursing homes and others who provide care and services to beneficiaries.

Delays in final determinations, according to the plaintiffs in a case filed in April 2017, violate the Medicaid Act's requirements and have resulted in delayed payments for long-term care and other services.

Four women who were residents of supportive living facilities or nursing homes brought the case after seeking Medicaid coverage through the state in 2015 and 2016. They wanted the lawsuit to be certified as a class action on behalf of Illinois Medicaid applicants for long-term care benefits whose applications are pending.

U.S. District Judge Joan B. Gottschall on Thursday certified the class to include any Illinois resident who had applied for Medicaid after Feb. 1, 2015, and had been deemed eligible for long-term care benefits but had not yet received a final eligibility determination or hearing notice within a certain number of days — 45 in non-disability cases and 90 in disability cases.

The class also includes all those who were determined to be eligible to receive long-term care Medicaid benefits from the state on or after Feb. 1, 2015, but who are still waiting to be deemed “admitted” to a long-term care facility.

In Illinois, Gottschall noted, a “favorable” eligibility determination is required to receive benefits, but for supportive living and nursing facilities to be paid, a beneficiary then “must be processed as ‘admitted' in an [Illinois Department of Healthcare and Family Services] computer system called ‘MEDI.' ”

One plaintiff in the case, Alma Koss, first applied for long-term care Medicaid benefits in August 2015. “She submitted allegedly missing documents the next month, and she had yet to receive a determination on her first application when the complaint was filed,” Gottschall noted in her ruling.

Koss completed a second application in June 2016, and the next month, the Illinois Department of Human Services said she was eligible for basic benefits retroactive to May 2016, Gottschall wrote. As a result, Koss alleges, the supportive living facility at which she has lived since August 2015 has not been paid. Also, Koss alleges, her ophthalmologist has not been paid and, therefore, would not treat her. Koss maintains that she is now blind because she did not receive eyecare.

Since the claim was filed, one of the original plaintiffs has died and another withdrew from the case. In her ruling Thursday, however, Gottschall said that others could join in the remaining plaintiffs' case.

She also said that the state must determine long-term care benefit eligibility for members of the class before June 28. Beginning June 28, the state must pay long-term care and other Medicaid benefits to (or for the benefit of) class members while their applications are pending beyond the Medicaid Act's deadlines for eligibility determination.

The state also must file an update on its efforts to comply with the ruling by the end of this month. A status conference has been set for May 9.

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