When Medicaid managed care organizations (MCOs) improperly deny services, lives are put at risk. Kamryn and Kyara Lambert are 16-year-old twin sisters with complex medical needs resulting from their premature births. Because of their primary diagnoses of periventricular leukomalacia and autism, they require total assistance in all areas of daily living and constant supervision to prevent injury. Their Medicaid MCO previously provided two home health aides to ensure personal attention was always available. But suddenly and inexplicably, the MCO completely denied the services of one aide. The twins’ mother, Kym, immediately called PHLP for help because both children’s health and safety would be jeopardized if they were required to share one aide.
The twins’ primary care physician strongly believed two home health aides were necessary and provided supportive testimony when PHLP represented the twins during their service denial hearing. Moreover, the Medicaid MCO failed to provide any documentation showing that the twins’ medical condition had changed; their condition remains fragile.
A few hours after the grievance hearing concluded, the Medicaid MCO reversed itself. Furthermore, the state instructed that MCO that it cannot deny home health aide services solely on the basis that a parent can perform those tasks, unless the MCO can provide documentation attesting to the fact that the parent is actually available and able to provide the extent of care required, considering the parent’s work schedule and other responsibilities both inside and outside of the home. No documentation establishing parental availability had been provided by the MCO in support of the twins' denial of services