[Youth-list] On Medicaid/HUSKY denials of service

[yalie4567 at aol.com]

The following was sent by an attorney at New Haven Legal Assistance (Sheldon Toubman, stoubman at nhlegal.org) - and may be of interest and use?to all of you who work with children, youth and parents on Medicaid/HUSKYA.? Contact him directly if issues arise:

We in legal services are always interested in referrals of any denials of medical treatment by any of the four Medicaid HMOs (WellCare, Anthem ("Blue Care Family Plan"), Health Net and Community Health
Network of CT).? This is particularly true for any denial of services where the enrollee or provider is told that the requested services or items are "not covered" by the plan or Medicaid and the enrollee is
under 21-- not just for prescription drugs.? This is because, under federal Medicaid law and the 4 HMOs' contracts with DSS, there is no such thing as medical treatment which is not covered for a Medicaid
enrollee under 21 (with the possible exception of truly experimental treatment). 

The language in the HMO contracts regarding this requirement appears at Section 3.18.d., which states that the HMO must provide "all medically necessary health care, diagnostic services, and treatment for Members under twenty-one (21) covered under the federal Medicaid program ... [which is pretty much the universe of all conceivable types of medical treatment in Western medicine and beyond] ... regardless of any limitations on the amount, duration, or scope of the services that would
otherwise be applied."

Translation: if a Medicaid HMO ever denies a requested service or item to a child on the ground that the service is "not covered," regardless of the type of treatment, bells should go off and, besides suggesting an immediate appeal, you should consider a referrral to legal services. 

If the enrollee is an adult, there are very few services that are "not covered" even for this group, and please also consider a referral for them. We can help the individual and, in the case of a systemic problem such as the deceptive "not covered" pharmacy messages, we can potentially bring systemic improvements.
Thank you.
Sheldon

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