District of Columbia Responds to FOIA Request Concerning the Implementation of Federal Court Order Providing Relief to Medicaid Applicants and Beneficiaries

On July 12, 2016, the U.S. District Court entered an Order in the long-running Salazar v. District of Columbia class action case providing immediate relief to self-identified Medicaid applicants and beneficiaries who cannot access their benefits as a result of the District of Columbia’s delays and errors in processing eligibility applications and renewals.  More information about the July 12, 2016, Order and how to obtain relief under it is provided in our August 25 and September 28 posts. 

On September 27, 2016, Terris, Pravlik & Millian, LLP, class counsel for the Salazar v. District of Columbia plaintiff class of Medicaid applicants and beneficiaries, submitted a request under the District of Columbia’s Freedom of Information Act (FOIA) for policies, procedures, and training materials developed by the District of Columbia to implement the relief in the Order entered by the U.S. District Court on July 12, 2016.

In its FOIA Response, the District provided 68 pages of documents detailing how it processes requests for provisional Medicaid, in the case of applications, and for extended Medicaid, in the case of renewals, under the July 12 Order.  The District also provided sample notices for applicants and beneficiaries who submit a claim for relief under the July 12 Order.  

If you or someone you represent is a non-disabled applicant who has been waiting longer than 45 days for a Medicaid eligibility determination and have submitted a claim seeking relief under the Court’s July 12 Order, be sure to request a notice from the District of Columbia informing you whether the relief has been granted.  

If you or someone you represent is a Medicaid beneficiary of any kind, including a QMB, EPD-HCBS, IDD, and Long-Term Care Nursing Home beneficiary, and whose benefits are about to be terminated at renewal or recertification or have already been terminated, even though you did not receive advance notice of the need to renew or you timely submitted all required forms and supporting documents, and have submitted a claim seeking relief under the Court’s July 12 Order, be sure to request a notice from the District of Columbia informing you whether the relief has been granted.

If you disagree with District’s determination, please call Terris, Pravlik & Millian, LLP at 202-682-0578 for free legal help or email us at medicaidhelp@tpmlaw.com.

Terris, Pravlik & Millian, LLP Will Provide Free Legal Help for Delayed Medicaid Applications or Problems with Medicaid Renewals

If you or a client is waiting more than 45 days for a decision on a District of Columbia Medicaid application or has lost or is threatened with the loss of Medicaid coverage at renewal (also known as recertification), either without notice or after having turned in all required forms, call Terris, Pravlik & Millian, LLP at 202-682-0578 for free legal help or a referral. You may also email us at medicaidhelp@tpmlaw.com.

Terris, Pravlik & Millian, LLP, class counsel for the Salazar v. District of Columbia plaintiff class of Medicaid applicants and beneficiaries, provides free legal help for many problems involving Medicaid applications and renewals.  We provided more information about a July 12, 2016, Order providing relief to Medicaid applicants and beneficiaries here.

The District of Columbia Medicaid agency has forms to be submitted if you wish to submit a claim for relief concerning a Medicaid application or renewal without a lawyer.  Fill out a renewal or application claim form and submit it to dpo.deputy@dc.gov, at any Department of Human Services (DHS) service center* or make a claim by telephone at the Medicaid customer service line: (202) 727-5355.   Keep a record of what you submit.  If you have any problems, please call us for help:  202-682-0578. 

Information for DHS service centers is as follows: 

Anacostia

2100 Martin Luther King Avenue, SE

(202) 645-4614 (phone)

(202) 727-3527 (fax)

Congress Heights

4001 South Capitol Street, SW

(202) 645-4525 (phone)

(202) 645-4524 (fax)

Fort Davis

3851 Alabama Avenue, SE

(202) 645-4500 (phone)

(202) 645-6205 (fax)

H Street

645 H Street, NE

(202) 698-4350 (phone)

(202) 724-8964 (fax)

Taylor Street

1207 Taylor Street, NW

(202) 576-8000 (phone)

(202) 576-8740 (fax)

Federal Court Ruling Provides Immediate Relief to District of Columbia Medicaid Applicants and Beneficiaries

On July 12, 2016, the District Court entered an Order in the long-running Salazar v. District of Columbia class action case providing immediate relief to self-identified Medicaid applicants and beneficiaries who cannot access their benefits as a result of the District of Columbia government’s delays and errors in processing Medicaid eligibility applications and renewals. 

First, the District must grant provisional eligibility to all individuals who inform the government that more than 45 days have elapsed without a determination on their non-disability application for Medicaid benefits. The District must grant provisional eligibility to such individual applicants until it makes an eligibility determination on the application and provides them written notice of the decision.

Second, the District must provide continued eligibility to all Medicaid beneficiaries who inform the government that their Medicaid benefits are about to be terminated at renewal or recertification or have already been terminated, even though they did not receive advance notice that they needed to renew or they timely submitted all required forms and supporting documents. The District must continue these beneficiaries’ eligibility until it makes a determination on their renewal or recertification and provides them written notice of the decision. 

Individuals who believe they have one of these claims should contact plaintiffs’ counsel, Terris, Pravlik & Millian, LLP at (202) 682-0578 for free legal assistance, or the District government through the Medicaid customer service at line at (202) 727-5355, at any of its Service Centers, or at dpo.deputy@dc.gov.  

The July 2016 relief is a partial win for Medicaid applicants and beneficiaries, who first sought a preliminary injunction in December 2015.  They later sought, in February 2016, a modification of an existing consent decree seeking permanent relief for Medicaid applicants and beneficiaries without access to Medicaid benefits as a result of the District’s systemic failure timely and adequately to process applications and renewals.  In their papers, plaintiffs presented evidence of severe backlogs in the processing of thousands of applications and systemic delays and mishandling of paperwork at the time of renewal or recertification, arguing that the District was depriving these individuals of their constitutional and statutory rights. With the support of some of the major Medicaid advocacy and health organizations in the District, including the District of Columbia Legal Aid Society, Bread for the City, Whitman Walker Health, and Legal Counsel for the Elderly, plaintiffs presented dozens of examples of individuals who were denied health care and incurred out-of-pocket expenses through no fault of their own.

On April 4, 2016, the District Court granted in large part the relief sought by the plaintiff class, with some modifications, finding that “severe and technical and logistical problems in the processing of initial Medicaid applications and in the Medicaid benefits renewal process * * * have affected thousands of Medicaid beneficiaries and have deprived many District residents of necessary medical care to which they are entitled.”  However, shortly after the entry of the Court’s Order, the District of Columbia obtained a stay of the order and sought an appeal of it in the court of appeals.  The appeal of the April 4, 2016 Order is pending.

In the meantime, individuals who come forward with one of the claims described above can obtain immediate relief provided by the Court’s July 12, 2016 Order.  

Following the Court’s May 18, 2015 Ruling in Salazar, Medicaid Implements New Procedures for Reimbursement of Out-of-Pocket Expenses

The District of Columbia has issued a new transmittal informing managed care organizations, providers, and the public about changes affecting reimbursement of out-of-pocket medical expenses for Medicaid beneficiaries as a result of the District Court’s May 18, 2015, Memorandum and Order in Salazar v. District of Columbia.

Prior to the Court’s May 18, 2015, Memorandum and Order, all D.C. Medicaid-eligible individuals who incurred an out-of-pocket expense for drug prescriptions, doctor visits, or hospitalizations when they were eligible for Medicaid could potentially seek and receive free legal assistance from Terris, Pravlik & Millian, LLP to submit a claim for reimbursement.  If the Medicaid recipient was unsatisfied with the District of Columbia’s decision, she could seek a fair hearing before the Office of Administrative Hearings (“OAH”) to contest it.  If the Medicaid recipient was unsatisfied with the OAH decision, she could appeal it to Judge Gladys Kessler of the U.S. District Court for the District of Columbia.  Terris, Pravlik & Millian, LLP would provide free legal assistance throughout this process.

The Court’s May 18, 2015 Memorandum and Order made several changes to these procedures.  First, only Salazar class members may now obtain free legal assistance from Terris, Pravlik & Millian, LLP, concerning claims for reimbursement.  Non-class members may obtain free legal assistance from other legal aid service agencies in the District of Columbia.  

Salazar class members who can receive free legal assistance from Terris, Pravlik & Millian, LLP, are those individuals who were eligible for Medicaid or should have been eligible for Medicaid, but were forced to incur a medical expense for any of the following reasons:

1. There was a delay in excess of 45 days in the processing of the individual’s Medicaid application.
2. The pharmacy, clinic, hospital, or doctor’s office stated that the recipient was not eligible when she was eligible.
3. The District of Columbia improperly terminated, suspended, or discontinued an individual’s Medicaid eligibility at the time of renewal or recertification.
4. In the case of a child under 21 years of age, if the child was denied any Early and Periodic Screening Diagnostic Treatment service, including medical services, dental services, medication, medical equipment, supplies, or transportation services to Medicaid appointments.
5. In the case of newborns, who lack immediate Medicaid coverage using the Medicaid number of their mothers, but are eligible for Medicaid at the time of their birth.

Second, if an individual is not happy with the results of the fair hearing before the OAH, she must now appeal the decision to the District of Columbia Court of Appeals, rather than the U.S. District Court for the District of Columbia.

As a result of the Court’s May 18, 2015 Memorandum  Opinion and Order, individuals who previously received free legal assistance to submit claims for reimbursement , but are not Salazar class members will no longer be able to obtain free legal assistance from Terris, Pravlik & Millian LLP.  These individuals include (a) Qualified Medicare Beneficiaries, who are being billed by medical providers that only accept Medicare and not District of Columbia Medicaid, (b) beneficiaries who failed to present their Medicaid or Managed Care Organization card at the point of service, and (c) beneficiaries who inform their provider of their Medicaid eligibility but are being billed for medical expenses. 

Non-class members may obtain free legal assistance from Bread for the City Legal Clinic, (202) 265-2400, Legal Aid Society, (202) 628-1161, Legal Counsel for the Elderly, (202) 434-2120, Neighborhood Legal Services, (202) 269-5100, and University Legal Services, (202) 547-4747.  

Non-class members may submit a claim for reimbursement on their own and send letters to providers to request that they stop billing them for medical expenses.   If you are a Qualified Medicare Beneficiary, contact us for more information about what you can do to resolve billing issues. 

TPM Files Motion to Prevent the District from Improperly Terminating Medicaid Recipients at Renewal and Making Applicants Wait More than 45 Days for Eligibility Determinations

On December 22, 2015, Terris, Pravlik & Millian, LLP, filed a motion for a preliminary injunction against the District of Columbia in the United States District Court for the District of Columbia on behalf of the Salazar plaintiff class.  The preliminary injunction seeks to ensure that no Medicaid applicant (non-disabled) waits longer than 45 days for a decision on an application for Medicaid benefits and that no Medicaid recipient’s coverage is improperly terminated as a result of the District’s inability to make correct and timely eligibility decisions at the time of renewal or recertification.  The District of Columbia has until January 15, 2016, to respond.

Class counsel filed the preliminary injunction after hearing increasing concerns from class members, medical providers, and Medicaid advocates about the technological and other problems causing excessive delays for Medicaid applicants and improper terminations for Medicaid recipients.  In addition, DC has announced that there will be no passive renewals for Medicaid for a period of time beginning on January 1, 2016. 

Plaintiffs presented documents produced by the District of Columbia in response to Freedom of Information Act (FOIA) requests which show that the District of Columbia is depriving thousands of Medicaid applicants of their right to have their applications processed within 45 days.  As of December 10, 2015, there was a backlog of approximately 4,500 Medicaid applicants who applied in DC Health Link, the District’s health insurance online exchange, who have been waiting more than 45 days for a decision, with an additional backlog of paper applications.  Plaintiffs show in their motion that the District of Columbia routinely loses or fails to process application paperwork, forcing applicants to resubmit paperwork and stand in line at service centers for hours.

At the time of renewal, the District of Columbia is also depriving Medicaid recipients of their right to receive Medicaid benefits until found to be ineligible and to receive advance notice and an opportunity for a hearing prior to termination of their benefits.  Technological problems caused by the District’s poorly functioning computer systems routinely cause improper termination of benefits at the time of renewal or recertification.  In addition, plaintiffs show that despite the District of Columbia’s efforts, ongoing systemic document processing problems cause benefits to lapse, leaving otherwise eligible families and children without access to needed healthcare and medications, with burdensome out-of-pocket expenses, or high medical bills.

The Salazar plaintiff class seeks to have the Court enter an injunction requiring all applicants to be added to the Medicaid rolls within 45 days of their application and requiring that no recipient be terminated at renewal until the District of Columbia can demonstrate to the Court, based on substantial evidence, that their technology and business processing systems for making timely eligibility determinations on applications and renewals, and providing adequate notice to Medicaid recipients and applicants of such decisions, are functioning as required to ensure and protect their rights under the United States Constitution and applicable federal law and regulations.

Plaintiffs’ motion is supported by FOIA documents provided by District of Columbia agencies, the testimony of class members, the Legal Aid Society of the District of Columbia, Whitman-Walker Health, Bread for the City, Legal Counsel for the Elderly, and the DC Fiscal Policy Institute.  The motion and supporting documentation are available through Dropbox at the following link:

https://www.dropbox.com/sh/nuzr290yc5s4weq/AACI339sLZyrUGYUnF6x5vyxa?oref=e&n=363363361

TPM Wins Affirmance in Federal Appeals Court of Fee Award Based on Rates Calculated with the Legal Services Index (LSI) Update to the Laffey Matrix.

Civil rights litigation can be brought by individuals who do not have the funds to pay for lawyers because of the fee-shifting provisions of 42 U.S.C. 1988.  Section 1988 provides that a court may award attorneys’ fees at market rates when the plaintiffs win the case.

Counsel for the Salazar plaintiff class sought an award of fees under the Laffey matrix.  The Laffey matrix is a schedule of hourly rates for lawyers handling complex federal litigation that was developed in Laffey v. Northwest Airlines Inc., 572 F. Supp. 354 (D.D.C. 1983), affirmed in part and reversed in part on other grounds, 746 F.2d 4 (D.C. Cir. 1984), overruled in part on other grounds, Save Our Cumberland Mountains v. Hodel Inc., supra, 857 F.2d at 1525. 

For years, the Salazar class and the District of Columbia have been engaged in litigation over whether the fees awarded to class counsel should be based on the Legal Services Index (LSI) Update of the Laffey Matrix or the CPI Update of the matrix used by the United States Attorney’s Office (USAO).  The class presented substantial evidence that the LSI-Updated Laffey Matrix produced hourly rates that were below, but more closely aligned with, market rates than the USAO Laffey Matrix.  The District maintained that the LSI was national, not local like the CPI, its rates compared to those of large firms, not the small firm representing the class, and that the USAO Matrix was used in the vast majority of fees decisions in the District of Columbia.

In four decisions, Judge Gladys Kessler awarded fees based on the LSI-Updated Laffey Matrix; each time finding that the LSI was the preferred index for legal services and that the LSI-Updated Matrix was a conservative estimate of the cost of legal services in the District of Columbia.  Although the District abandoned an earlier appeal, it pursued an appeal of the third and fourth decisions.  

The D.C. Circuit affirmed Judge Kessler’s award of attorneys’ fees using the LSI-Updated Laffey Matrix.  Salazar v. District of Columbia, 809 F.3d 58 (DC Cir. 2015).  The D.C. Circuit agreed with Judge Kessler that the evidence presented by plaintiffs demonstrates that the LSI-Updated Laffey Matrix “’is probably a conservative estimate of the actual cost of legal services in this area’” (emphasis in original).  809 F.3d at 65.  It concluded that “[t]he District, neither below nor on appeal, rebuts this logic with relevant arguments.”  Id., at 65.  The Court noted that the fact that other courts have applied the USAO Laffey Matrix “is not compelling.” Id., at 65, n. 1.

The D.C. Circuit also reiterated its prior en banc holding that fees should not be calculated any differently when the losing defendant is the government.  809 F.3d at 65.  

Click for the decision here and for documents in the joint appendix here.

Terris, Pravlik & Millian, LLP, which represents the Salazar class, has made the evidence supporting the LSI-Updated Laffey Matrix available on its website at this link.  

The Salazar case is a class action brought on behalf of adults and children, pursuant to 42 U.S.C. 1983, to enforce various provisions of the Medicaid Act. The class is currently monitoring the District’s compliance with the consent decree entered in 1997 and amended in 1999.  The class periodically files fee applications.  Click here for more information regarding the case.