What you need to know about Michigan Due Process and Services for DD

Spring at last

I attended two presentations in the last 6 weeks by Stacy Coleman sponsored by NAMI (National Alliance on Mental Illness) of Washtenaw County, Michigan, and the Washtenaw Community Health Organization (WCHO). Stacy works for the WCHO and is a Medicaid Hearing Officer. She is an expert on Medicaid law as it pertains to people served by the Community Mental Health system. Her presentations on due process rights and mental health services for people with mental illness and developmental disabilities are always informative.

This was a refresher course for me (see the Friends of DD Newsletter from November 2010) and a reminder that many families of people with DD are not well-informed about their family member's rights, the availability of services, or the remedies afforded to Medicaid recipients who disagree with decisions made by their local CMH. It is not only a lack of information that is the problem, but the reality that many families are sometimes misinformed and misled by people within the CMH system.

Here are a few bits of information from Stacy's presentation that you need to know:

IN MICHIGAN, THERE ARE NO WAITING LISTS FOR SERVICES

Because of agreements Michigan made with the Federal agency that regulates Medicaid (CMS) that allows the state to have a managed care system for Medicaid-funded mental health services, there can be no waiting lists for services.

MEDICAL NECESSITY

Mental Health Services for people with DD must be"Medically Necessary". The same criteria apply to people with mental illness.

According to the Michigan Medicaid Provider Manual, individuals with developmental disabilities who are eligible for Medicaid are entitled to "medically necessary" supports, services, and treatment that are:

• Necessary for screening and assessing the presence of a developmental disability
• Required to identify and evaluate a developmental disability
• Intended to treat, ameliorate, diminish, or stabilize the symptoms of developmental disability
• Are expected to arrest or delay the progression of a developmental disability
• Are designed to assist the individual to attain or maintain a sufficient level of functioning in order to achieve his goals of community inclusion and participation, independence, recovery, or productivity.

The determination of medical necessity must be based on information provided by the person with a DD, the person’s family and/or others who know the individual, and clinical information from health care professionals. The determination must be based on a person-centered plan and made by appropriately trained developmental disabilities professionals within federal and state standards of timeliness. It must be "sufficient in amount scope, and duration of the services" and documented in the Individual Plan of Service.

Services "sufficient in amount, scope, and duration" need to be specified in the IPOS with as much detail as is necessary to meet the needs of the person.

Services may not be denied based solely on present limits of the cost, amount, scope, and duration of services. Determination of the needs for services shall be conducted on an individual basis.

WRITTEN NOTICE FOR ADVERSE ACTIONS

When you ask for a service (do this in writing to make sure you have documentation of the request), the CMH agency must give you a written notice if the agency decides:

• to deny or limit the service
• reduces, terminates or suspends the service, denies payment for a service in whole or in part, or fails to authorize a service

In most cases the CMH agency must give you advance notice of an "adverse" action 12 calendar days before the action takes effect, or they must give you notice at the time the Individual Plan of Service is completed.

MEDICAID HEARINGS 

You may ask for a state Medicaid hearing through the Michigan Department of Community Health if you do not agree with the decision of the PIHP (the WCHO in Washtenaw County). Go to the Michigan Department of Community Health website for more information and a "Request for Hearing" form.

Services must continue while a hearing decision is pending if you have asked for the hearing in a timely manner. See the WCHO website on hearings and appeals for more information.

Here is more on the WCHO regional Due Process and Appeal Committee with links to related documents including the Medicaid Provider Manual.