WHERE IS THE “CARE”
IN MEDICAID MANAGED CARE?

This is a question Molly and Anne M. have asked ever since Molly was unable to get needed health care services in 1998. Their experiences caused them to ask two other questions: Is care effectively “managed” in managed care? Are the Fair Hearings supposedly available to correct problems really “fair”?

Anne, who is Molly’s mother, fought for nearly two years to get positive answers to these questions. Her perseverance was rewarded, at least in part, when a state judge ruled on April 10, upholding her complaints that Molly’s appeal hearing had been unfair.

At the end of February 1998, Molly, who had been receiving residential treatment, was about to be discharged. It was agreed that she needed immediate, regular follow-up care.

Molly’s Medicaid managed care plan even issued an “authorization” for the follow-up care. The only problem was, they never told Anne and Molly about it, and they didn’t send it to the treating provider for several days. As a result, Molly’s attempts to get the follow-up care she needed were delayed, and eventually thwarted when one therapist took it upon herself to countermand the post-discharge treatment plan.

Anne filed grievances with her managed care plan, which, in violation of state regulations, never responded. Meanwhile, Molly’s condition deteriorated, and she experienced severe problems as a result. According to Anne, “I believe that she lost a year of her life.”

Despite the plan’s lack of response to Anne’s complaints, she continued to fight for the managed care Molly and other Medicaid recipients are supposed to receive. Aided by P&A, Anne appealed the care denials and lack of care coordination through the state’s fair hearing system. Unfortunately, that hearing was anything but fair. Anne’s complaints about the plan’s violation of its managed care obligations were disregarded. She was forced to “attend” the hearing by telephone, while the plan’s representatives sat with the hearing officer and the state’s attorney, and were given free reign to argue their case. Consequently, the appeal judge denied Molly and Anne’s claims. It was this ruling that the state judge overturned as unfair.

Today, thanks to the availability of alternative services, Molly’s condition is much improved. She and Anne are delighted that someone—in this case a state judge—has finally heard their complaints. But, as Anne has long maintained, she has fought to make the managed care system work properly for all recipients who need prompt, coordinated, managed care. That goal still remains.