By Martha A. Churchill

The federal government passed a law setting minimum requirements for Medicaid. When a state decides to offer Medicaid, and accept federal money for the program, the state is required to provide those things.

This essay gives you information about actual legal cases involving people with disabilities, and the services they were entitled to.

In Michigan, the Community Mental Health offices (CMH) are legally required to provide certain things for persons with mental illness, and for persons with developmental disabilities.  Those things are found at the Michigan Department of Community Health website, click on MDCH for the link.  The CMH offices also have a signed contract with the Department of Community Health, outlining what CMH is supposed to do for people with disabilities.  To read my notes on it, click on CONTRACT.  An important part of that contract is known as the Best Practices Guidelines.  To read that, click on BPG.

You don’t have to be a lawyer to understand this, but if you want to look up the law, go to 42 USCA 1396a(a).

Anyhow, Michigan made a deal with the federal government, through HCFA (Health Care Finance Administration) to offer these services to Medicaid recipients. Each state can decide whether to offer the minimum requirements, or some of the extras. That law is known as 42 USCA 1396d(a)(1) through (27).

If CMH does not provide what you need, you can enforce your rights through a Medicaid fair hearing request.    

Once a state makes a deal with HCFA, the agreement is written in stone. The state has to provide whatever services it promised HCFA. However, if there is a shortage, that is okay so long as the state provides some reasonable alternatives to the exact type of services people want the most. King v. Fallon, 801 F. Supp. 925 (D.R.I. 1992).

The state can’t decide to help some people with a particular disability and not others, just because of the way the disability was caused. There was a federal court case that ordered the state of Pennsylvania to treat everybody with poor eyesight the same, and pay for their eyeglasses, no matter what caused their vision problems. White v. Beal, 555 F.2d 1146 (3rd Cir. 1977).

If there is only one treatment that works well for the Medicaid recipient, the state has to pay for it, even though the treatment is expensive. Missouri found that out when some Medicaid recipients with AIDS asked for the drug AZT. The state tried to pass a rule that it would never pay for AZT. However, the court wrote an order forcing the state to pay for the drug if the person’s doctor prescribed it. Weaver v. Reagen, 886 F. 2d 194 (8th Cir. 1989).

A woman with cerebral palsy asked for Medicaid to pay for her "Complete B" processed food. The state turned her down, and she lost her case because she didn’t have medical evidence showing that her physical problems were caused by her parents feeding her a home formula. Shappell v. Public Welfare, 445 A. 2d 1334 (Pa. 1982).

There was once a case in Iowa where someone asked Medicaid to pay for sex reassignment surgery. The state refused. Iowa even had a special rule excluding sex change operations from Medicaid coverage. But the court disagreed. The judges said that the surgery improved the person’s health, and it was the only way to alleviate the person's condition, so Medicaid had to pay for it. Pinneke v. Preisser, 623 F. 2d 546 (8th Cir. 1980).

A state is not supposed to use waiting lists to keep people from getting the services they need, even if the budget is short of money. California tried to make people wait for services at Medicaid funded drug treatment centers. The federal courts ordered California to provide services with "promptness" rather than making people wait. Sobky v. Smoley, 855 F. Supp. 1123 (E. D. Cal. 1994).

Texas tried to save money on Medicaid by forcing people to use an ambulance if they needed transportation. As a result, no one could get transportation unless it was an emergency and they were going to the hospital. Someone with cerebral palsy sued, forcing Texas to pay for regular transportation to routine doctor appointments without having to use an ambulance. Smith v. Vowell, 379 F. Supp. 139 (W. D. Tex. 1974).