|Spring at last|
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.
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.
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
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.