Interpreting Medicaid regs

Law.com has an article from today's Fulton County Daily Report on the oral argument in an 11th Circuit case, "Medicaid Suit Could Determine Who Decides Care: Doctor or State".  The case is Moore v. Medows, No. 08-13926 (District Court opinion at 563 F.Supp.2d 1354).  The article's subtitle is "Federal appeals court hears arguments in case that Medicaid managers say could impact states' flexibility and discretion in allocating resources". 

[The plaintiff's] mother filed suit in 2007 after the state told her it was reducing Callie's number of paid nursing hours from 94 hours a week to 84.

The Moores' lawyers convinced U.S. District Judge Thomas W. Thrash Jr. that the reduction was improper. The judge concluded the state must provide for the amount of skilled nursing care that Callie's treating physician deems necessary.

Thrash's June 4, 2008, ruling has states and Medicaid plan managers up in arms. They say that Thrash's order means that states won't have the flexibility they need and the discretion the law allows to allocate Medicaid resources fairly.

Federal law requires states participating in the Medicaid program to provide care that's necessary to "correct or ameliorate defects and physical and mental illnesses" in lower-income children under the age of 21. The state points to a federal regulation that says Medicaid agencies may place limits on service based on "medical necessity."

The state Department of Community Health operates a program to administer Medicaid-funded nursing services for several hundred children who need nursing care. It delegates the decisions about approval of such services to an organization called the Georgia Medical Care Foundation. That organization made the decision to reduce Callie's hours of nursing care, contrary to the recommendation of Callie's primary care physician.

The state says in its briefs that nursing hours can be reduced when the patient's medical condition stabilizes, positing that a goal of its program is to teach parents and other caregivers to care for the child on their own. The Moores' lawyers at the Georgia Advocacy Office, a nonprofit that advocates for disabled people, contend that the state's system of "weaning" patients off their nursing services as long as they're staying out of the hospital and not getting worse follows a different standard than that set by federal law.

I suggest that this is going to be an interesting case to watch, and that it will turn on the 11th Circuit's interpretation of the Medicaid statute and regulations.  EMM