1. law, govt and politics

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF PENNSYLVANIA
MELISSA MENDEZ and
AMINATA DIAO
on behalf of themselves and all others
similarly situated,
Plaintiffs
v.
BEVERLY D. MACKERETH,
Secretary of the Pennsylvania
Department of Human Services,
and
DIONISIO MIGNACCA,
Executive Director of the Philadelphia
County Assistance Office,
Defendants.
: CIVIL ACTION
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: NO. 2014:
: COMPLAINT
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: CLASS ACTION
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COMPLAINT
PRELIMINARY STATEMENT
1. This action challenges the Pennsylvania Department of Human Services’ (DHS’s,
formerly the Department of Public Welfare’s, or DPW’s) processes for implementing severe cuts
in Medicaid benefits for adults in Pennsylvania. More than 1.1 million low-income and
vulnerable individuals have been assigned to one of three Medicaid benefits packages with new
limitations on services, on or after January 1, 2015, through the use of three algorithms with
secret standards. DHS has sent two rounds of inadequate notices that first did not explain that
benefits are being cut, and then did not provide any legal authority for the cuts. Due to
implementation of these secret algorithms with inadequate notice, Medicaid and state funded
Medical Assistance recipients with disabilities or other serious health problems that make them
“medically frail” are being assigned to less generous benefits packages that do not meet their
medical needs, resulting in potentially serious but avoidable medical problems, as well as
needless confusion.
2. DHS administers Pennsylvania’s Medicaid program as well as a state funded Medicaid
lookalike program known as Medical Assistance, most of whose recipients will be transitioned to
federally funded Medicaid starting January 1, 2015. As part of its “Healthy Pennsylvania”
initiative, DHS is electing to limit Medicaid benefits for adult Medicaid recipients beginning on
January 1, 2015, with severe limitations for some. While federal law confers upon states some
latitude in designing Medicaid benefits packages, states must comply with due process
requirements of the United States Constitution, as well as the detailed federal statutory and
regulatory Medicaid scheme. The Social Security Act and its implementing regulations require
that states administer Medicaid “in a manner consistent with simplicity of administration and the
best interests of the recipients,” using “reasonable standards.”
3. This class action seeks declaratory, injunctive, and notice relief on behalf of adult
Medicaid and state funded Medical Assistance recipients who will be eligible for federally
funded Medicaid on or after January 1, 2015 and whom DHS has determined are not medically
frail and therefore assigned to lesser Medicaid benefits packages via unascertainable standards
with inadequate notice. DHS’s actions violate the Social Security Act and the Due Process
Clause of the Fourteenth Amendment to the United States Constitution.
4. The Plaintiffs seek to enjoin DHS from assigning Medicaid and state funded Medical
Assistance recipients to severely reduced benefits packages without using ascertainable standards
and without providing adequate and individualized notices.
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JURISDICTION
5. This Court’s subject matter jurisdiction over this action is conferred by 28 U.S.C. § 1331,
and by 28 U.S.C. § 1343(a)(3) and (4), which provide for jurisdiction over actions under the
United States Constitution and civil rights laws.
6. Plaintiffs’ claims for declaratory, injunctive, and other relief are authorized by 28 U.S.C.
§§ 2201 and 2202, Rule 57 of the Federal Rules of Civil Procedure, and by 42 U.S.C. § 1983.
7. Plaintiffs’ claims for attorneys’ fees and costs are authorized by 42 U.S.C. § 1988.
8. Venue is proper in the Eastern District of Pennsylvania pursuant to 28 U.S.C. § 1391.
PARTIES
9. Plaintiff Melissa Mendez is a citizen of the United States of America and a resident of
Philadelphia County, Pennsylvania.
10. Ms. Mendez is a 33-year-old recipient of state funded Medical Assistance benefits who
will receive Medicaid coverage on January 1, 2105. She has been improperly assigned to the
Healthy PA PCO Medicaid benefits package as a result of the Defendants’ unascertainable
standards and flawed procedures. She was sent inadequate notice of the cuts to her Medicaid
benefits by the Defendants.
11. Plaintiff Aminata Diao is a citizen of Mali and a resident of Philadelphia County,
Pennsylvania. She came to the United States in 2001 and was granted “withholding of removal”
status because she would be persecuted if she returned to her home country. She is lawfully
present in the United States, authorized to work, and eligible for public benefits.
12. Ms. Diao is a 37-year-old recipient of Medicaid benefits who has been improperly
assigned to the Healthy Medicaid benefits package as a result of the Defendants’ unascertainable
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standards and flawed procedures. She was sent inadequate notice of the cuts to her Medicaid
benefits by the Defendants.
13. Defendant Beverly D. Mackereth is the Secretary of the Pennsylvania Department of
Public Welfare (DHS). She is responsible for ensuring that DHS’s Medicaid program is properly
and efficiently administered according to reasonable standards, and that the Pennsylvania
Medicaid program complies with the Social Security Act, its implementing regulations, and the
United States Constitution. She is sued in her official capacity.
14. Defendant Dionisio Mignacca is the Executive Director of the Philadelphia County
Assistance Office. He is responsible for ensuring that the Philadelphia County Assistance Office
properly and efficiently administers the Medicaid program according to reasonable standards, in
compliance with the Social Security Act, its implementing regulations, and the United States
Constitution. He is sued in his official capacity.
CLASS ACTION ALLEGATIONS
15. Plaintiffs Melissa Mendez and Aminata Diao bring this action on behalf of themselves
and all others similarly situated, pursuant to Rules 23(a), (b)(2), and (c)(5) of the Federal Rules
of Civil Procedure.
16. The Plaintiff class consists of all current adult Medicaid and state funded General
Assistance-related Medical Assistance (GA-MA) recipients who will be eligible for federally
funded Medicaid on or after January 1, 2015 and whom DHS has not found to be medically frail,
resulting in their placement in the Healthy or Healthy PA PCO Medicaid benefits packages on or
after January 1, 2015.
17. The first subclass consists of all current adult Medicaid recipients who will be eligible for
federally funded Medicaid on or after January 1, 2015 and whom DHS has not found to be
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medically frail, resulting in their placement in the Healthy Medicaid benefits package on or after
January 1, 2015.
18. The second subclass consists of all current adult state funded General Assistance-related
Medical Assistance (GA-MA) recipients who will be eligible for federally funded Medicaid on
or after January 1, 2015 and whom DHS has not found to be medically frail, resulting in their
placement in the Healthy PA PCO Medicaid benefits package on or after January 1, 2015.
19. The requirements of Rules 23(a) and (b)(2) are met in that:
a. The class and the subclasses are so numerous that joinder of all members is
impracticable. A total of 197,566 current Medicaid and state funded GA-MA recipients have
been assigned to either the Healthy or Healthy PA PCO Medicaid benefits packages on or after
January 1, 2015, comprising the class. 149,606 current Medicaid recipients have been assigned
to the Healthy Medicaid benefits package on or after January 1, 2015, constituting the first
subclass. 47,690 current GA-MA recipients have been assigned to the Healthy PA PCO
Medicaid benefits package effective January 1, 2015, constituting the second subclass.
b. There are questions of law and fact common to the class and both subclasses, including
whether the Defendants’ practices violate the United States Constitution, and to the first
subclass, including whether the Defendants’ practices violate the Social Security Act. The
Defendants have used unascertainable standards and sent inadequate notice to all members of the
class and subclasses;
c. The claims of the representative parties are typical of the claims of the class members
and of the claims of the subclass members, and the representative parties will fairly and
adequately protect the interests of the class and subclasses. Moreover, Plaintiffs are represented
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by competent counsel who have represented classes and subclasses in numerous other cases
involving Medicaid and other public benefits programs; and
d. The Defendants have acted on grounds generally applicable to the members of the
class and the subclasses, thereby making appropriate final injunctive and declaratory relief with
respect to the class as a whole and with respect to each subclass as a whole.
LEGAL FRAMEWORK
20. Medicaid is a joint federal-state assistance program authorized by Title XIX of the Social
Security Act that provides health insurance coverage to certain low-income individuals.
Medicaid is administered by the states under the supervision of the United States Department of
Health and Human Services (HHS). 42 U.S.C. §§ 1396a-1369w-5. DHS administers the
Medicaid program for Pennsylvania.
21. The Social Security Act requires states to administer their Medicaid programs according
to reasonable standards. 42 U.S.C. § 1396a(a)(17).
22. The Social Security Act further requires states to operate their Medicaid programs “in a
manner consistent with simplicity of administration and the best interests of the recipients.” 42
U.S.C. § 1396a(a)(19).
23. Medicaid recipients with serious health problems that render them medically frail must be
assigned to Medicaid benefits packages that meet their health care needs. 42 U.S.C. § 1396u7(a)(2)(B)(vi); 42 C.F.R. § 440.315(f).
24. Under the Due Process Clause of the Fourteenth Amendment to the United States
Constitution, individuals have a right to have determinations of eligibility for Medicaid coverage
and services made according to ascertainable standards.
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25. Also under the Due Process Clause of the Fourteenth Amendment, individuals have a
right to meaningful, individualized notice, supported by legal authority, and an opportunity to be
heard before their Medicaid benefits are terminated or otherwise altered adversely.
26. The Social Security Act provides that any person who is denied assistance under his or
her state Medicaid program is entitled to an opportunity for a fair hearing. 42 U.S.C. §
1396a(a)(3).
27. Under the federal regulations that interpret and apply the Social Security Act and the Due
Process Clause of the Fourteenth Amendment, individuals have the right to advance notices that
fully explain the factual and legal bases for termination, suspension, or reduction of Medicaid
eligibility or covered services. 42 C.F.R. §§ 431.206-211, 431.230, & 435.919.
STATEMENT OF FACTS
Healthy Pennsylvania’s Medicaid Benefits Cuts
28. In September 2013, Pennsylvania Governor Tom Corbett announced an overhaul of
Pennsylvania’s Medicaid system, called “Healthy Pennsylvania.” Healthy Pennsylvania
includes new limitations on benefits for more than 1.1 million adult Medicaid and state funded
Medical Assistance recipients, effective January 1, 2015, with some recipients facing severe
benefits cuts. Also effective January 1, 2015, it features expansion of Medicaid for individuals
between the ages of 19 and 64 with incomes at or below 133% of the federal poverty guidelines
(plus a 5% income disregard), as authorized by the Patient Protection and Affordable Care Act
(ACA), Pub. L. No. 111-148, 124 Stat. 119 (2010). Though these two initiatives are linked by a
name and an implementation date, they are entirely separate initiatives and neither is dependent
on the other as a matter of law or fact.
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29. Until January 1, 2015, federal Medicaid coverage has only been available to specific
categories of low-income Pennsylvanians. These categories, which remain in effect, cover
children, seniors, individuals with significant and long-term disabilities, pregnant women, and
very low-income parents and other related caretakers of minor children. Each Medicaid category
has its own income and asset limits, as well as non-financial rules for determining eligibility.
30. Some states, including Pennsylvania, have opted to cover a few more categories of
individuals through state funded Medicaid lookalike coverage. In Pennsylvania, the state funded
program is called General Assistance-related Medical-Assistance (GA-MA). GA-MA coverage
is available to very low-income individuals in certain categories, including individuals with
shorter-term disabilities, survivors of domestic violence (for nine months in a lifetime), and
individuals in active treatment for drug and alcohol abuse (for nine months in a lifetime). As
part of the Healthy Pennsylvania initiative, all qualified GA-MA recipients will be transferred to
the new Medicaid expansion category on January 1, 2015.
31. As Pennsylvania’s state Medicaid agency, DHS is charged with implementing Healthy
Pennsylvania. In that role, DHS announced that it would provide three Medicaid benefits
packages beginning on January 1, 2015: the “Healthy Plus,” “Healthy,” and “Healthy PA Private
Coverage Option” (PCO) packages.
32. The Healthy Plus benefits package looks most like Pennsylvania’s existing Medicaid
coverage, with some changes and new limitations, particularly a $2,500 annual limit for medical
supplies like adult diapers, catheters, and colostomy bags. Pregnant women, seniors, and many
(but not all) individuals with serious and long-term disabilities will qualify for Healthy Plus
automatically. Medicaid recipients in other categories of eligibility will qualify for Healthy Plus
only if they are medically frail.
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33. The Healthy benefits package is significantly less generous than both the Healthy Plus
benefits package and current Medicaid benefits packages. Among other cuts, it includes new,
strict annual limits of four specialist doctor visits, six radiology tests, and $350 in laboratory
services. If they are not found to be medically frail, parents (and other adult relatives who are
caring for children) with very low incomes, young adults who have aged out of foster care, and
individuals awaiting enrollment in the Healthy PA PCO plan will be assigned to the Healthy
benefits package.
34. Named for Pennsylvania’s planned Medicaid expansion managed care network, the
Healthy PA PCO benefits package is less generous than the Healthy Plus benefits package, but
with different cuts in services than the cuts in the Healthy package. Most significantly, in 2015,
the Healthy PA PCO package will not provide non-emergency medical transportation for
individuals who are too sick and/or too poor to be able to transport themselves to their medical
appointments. It also will provide no dental coverage, reduced optometry services, and new
behavioral health managed care systems that are expected to have more limited provider
networks than traditional Medicaid. Current GA-MA recipients and individuals who are newly
eligible for Medicaid through expansion will be enrolled in the Healthy PA PCO benefits
package unless they are medically frail.
35. Federal Medicaid regulations require state Medicaid agencies to seek and obtain approval
of benefits packages from HHS prior to implementation. 42 C.F.R. §§ 430.10-20, 440.305(d).
On December 17, 2014, HHS approved the Healthy Plus and Healthy PA PCO benefits
packages. HHS has not yet approved the Healthy benefits package. As HHS approval of the
Healthy benefits package is not assured by January 1, 2015, DHS has stated that it intends to
keep Medicaid recipients assigned to the Healthy benefits package in their current benefits
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packages, or near equivalents, until HHS approves the Healthy package. Accordingly,
individuals assigned to the Healthy benefits package may not be subject to severe benefits cuts
until sometime after January 1, 2015. Other Medicaid recipients and GA-MA recipients will
receive the Healthy Plus and Healthy PA PCO benefits packages as planned on January 1, 2015.
36. Federal Medicaid regulations require state Medicaid agencies to develop definitions of
medical frailty that encompass, at the very least, “individuals with disabling mental disorders,
individuals with serious and complex medical conditions, and individuals with physical and/or
mental disabilities that significantly impair their ability to perform one or more activities of daily
living.” 42 C.F.R. § 440.315(f). DHS also deems individuals with chronic substance abuse
disorders as medically frail through a definition that it proposed as part of Healthy Pennsylvania
implementation, but has not promulgated as a regulation or published as subregulatory guidance.
37. DHS’s definition of medical frailty includes some additional details, but not many. For
example, it notes that an individual is medically frail if he or she has “a permanent disability that
significantly impairs their function,” and provides a few examples of qualifying disabilities, but
does not explain what the standard for demonstrating a significant impairment is.
38. Instead of elaborating on its definition of medical frailty to establish ascertainable
standards, in October 2014, DHS revealed on its Healthy Pennsylvania implementation web site
and through internal guidance that it would use complex and opaque internal systems, featuring
three secret algorithms, to determine which Medicaid applicants and recipients would be deemed
medically frail, and therefore eligible for the best Healthy Plus benefits package.
39. As a first step, DHS ran Medicaid claims data for current adult Medicaid and GA-MA
recipients through a “claims determination process” software algorithm to identify individuals
who are medically frail. DHS has not informed Medicaid recipients of how the claims
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determination process can or will analyze Medicaid claims data to determine which adult
Medicaid recipients are medically frail. It intends to use its claims determination process to
analyze claims data for Medicaid recipients when they complete mandatory annual
reapplications, and on a quarterly basis for Medicaid recipients assigned to the Healthy plan (but
not those assigned to the Healthy PA PCO plan). It also may use the claims determination
process to evaluate claims data for new Medicaid applicants who are known to DHS because
they received Medicaid in the past.
40. Beginning on November 5, 2014, DHS began sending “pre-transition letters” to Medicaid
and GA-MA recipients who were found medically frail by the claims determination process,
informing them that they would be enrolled in Healthy Plus. The same letters went to recipients
who qualify for Healthy Plus automatically by virtue of their Medicaid categorical eligibility,
because they are seniors or pregnant women, or have long term disabilities. A copy of the letter
is attached as Exhibit A.
41. Also beginning November 5, 2014, DHS began sending similar “pre-transition letters” to
Medicaid and GA-MA recipients who were not found medically frail by the claims
determination process, informing them that they will be enrolled in the Healthy or Healthy PA
PCO plans. Recipients of this second batch of letters were instructed that, if they believed that
their assigned benefits package would not meet their medical needs, they could complete a health
screening questionnaire, either online or by telephone, no later than November 26, 2014. A copy
of the “Healthy” letter is attached as Exhibit B, and a copy of the “Healthy PA PCO” letter is
attached as Exhibit C.
42. The pre-transition letters were misleading and deceptive. They did not state that
Medicaid benefits would be limited for all Medicaid and GA-MA recipients, effective January 1,
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2015. To the contrary, they stated that, “This initiative will ensure that Pennsylvanians have
increased access to quality affordable healthcare. As of January 1, 2015, coverage that you or
members of your household are receiving may change.”
43. The pre-transition letters referred to both the Healthy and the Healthy Plus plans as
“comprehensive,” with no details about how the plans differ or how Healthy is more limited.
44. The pre-transition letters did not inform individuals tentatively assigned to Healthy or the
Healthy PA PCO plan that, if they failed to complete a health screening questionnaire, they
would not get Healthy Plus.
45. The pre-transition letters did not confer appeal rights.
46. The pre-transition letters were at a level of complexity that required at least a year and a
half of college education to comprehend.
47. As a result of the misleading and deceptive statements in the pre-transition letters,
individuals tentatively assigned to the Healthy or Healthy PA PCO benefits packages were
unable to determine whether these benefit packages would meet their needs, and therefore
whether they should complete the health screening questionnaire.
48. The pre-transition letters advised recipients assigned to Healthy and Healthy Plus that
they could call various telephone numbers for information about the benefits packages.
Recipients and individuals attempting to assist them who called those numbers had great
difficulty in reaching DHS customer service representatives. Recipients and individuals
attempting to assist them who succeeded in reaching customer services representatives had
difficulty getting accurate information.
49. While DHS began mailing the notices on November 5, 2014, it sent the notices in
multiple waves over a nine-day period. The last notices were not mailed until November 13,
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2014. As a result, many individuals had a very short time frame for completing the health
screening questionnaire.
50. The pre-transition letters advised recipients that they could complete the health screening
questionnaire only via DHS’s online application portal or via a dedicated telephone call center.
Some Medicaid and GA-MA recipients who tried to complete the questionnaire online or over
the phone experienced difficulties with the online portal and/or the call center.
51. As a result of the misleading and deceptive pre-transition letters, the short time frame for
completing the screening questionnaire, and recipients’ difficulties in understanding the letters
and accessing the questionnaire, only 2,658 Medicaid and GA-MA recipients completed the
questionnaire by the November 26, 2014 deadline.
52. Recipients who could access the health screening questionnaire found that it asks a series
of closed-ended questions about recent medical situations and diagnoses. A copy is attached as
Exhibit D. There is no opportunity to explain individual circumstances that may make an
individual medically frail, such as unusual but debilitating medical conditions. The questions
ask for responses that may cause shame or be stigmatizing, such as whether a recipient has
HIV/AIDS, whether a recipient has been treated for use of street drugs, and whether a recipient’s
friend is concerned about his or her alcohol use.
53. Medicaid recipients who were first approved for Medicaid in November 2014 were not
sent pre-transition letters or given the opportunity to complete health screening questionnaire
because they were not receiving Medicaid at the time that the transition letters were generated,
and because the questionnaire was not incorporated into DHS’s initial Medicaid application
process until December 1, 2014.
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54. Similarly, individuals whose Medicaid is scheduled to close before January 1, 2015, but
who have a right to appeal the closure and receive benefits while their appeals are pending, have
not been provided with a mechanism either to complete the health screening questionnaire or to
have their current benefits packages continue pending resolution of their appeals.
55. Medicaid and GA-MA recipients who successfully completed the health screening
questionnaire were not guaranteed the Healthy Plus benefits package. Instead, DHS ran answers
to the questionnaire through a second secret algorithm – separate from the secret algorithm
underlying the claims determination process – to determine whether the recipient is
presumptively medically frail. The second secret algorithm will also be used to evaluate medical
frailty for new Medicaid applicants. DHS has refused to inform recipients of the second secret
algorithm.
56. Medicaid and GA-MA recipients whom the second secret algorithm determined were not
medically frail, or who did not complete the screening questionnaire, were assigned to the
Healthy or Healthy PA PCO benefits packages effective January 1, 2015.
57. Medicaid and GA-MA recipients found presumptively medically frail based on the
questionnaire and second secret algorithm will not be given the Healthy Plus package on a longterm basis automatically. Instead, they will be enrolled in Healthy Plus while their cases are
referred for “clinical validation” via a third secret algorithm.
58. DHS sent out “transition notices” with these plan assignments beginning on December 1,
2014. Copies are attached as Exhibit E.
59. The transition notices did not cite valid supporting legal authority for the new benefits
limitations for Medicaid and GA-MA recipients.
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60. The transition notices provided ten days from the dates printed on the notices for
recipients to appeal and receive Healthy Plus benefits pending fair hearings, as required by
federal law. See 42 C.F.R. §§ 431.211, 431.230. However, some notices were postmarked after
the dates printed on the notices, providing recipients with less than ten days to appeal.
61. The Healthy and Healthy PA PCO transition notices did not outline the specific reasons
why individual recipients do not qualify for Healthy Plus.
62. DHS’s “clinical validation” process for those found presumptively medically frail based
on the health screening questionnaire consists of telephone calls from DHS’s clinical staff to
Medicaid and GA-MA recipients’ medical providers. DHS has said that the clinical validation
team will ask about diagnoses, prognoses, and treatment plans, but it has refused to inform
recipients of the team’s call script or standards for determining medical frailty. Thus DHS has
created a third unascertainable standard in its clinical validation process.
63. Medicaid and GA-MA recipients who meet the clinical validation team’s secret standards
will remain in Healthy Plus. Medicaid and GA-MA recipients who do not meet the secret
standards will be moved from the Healthy Plus package to which they have been tentatively
assigned to the less generous Healthy and Healthy PA PCO packages. DHS has not developed
an appeals process for recipients who are moved out of Healthy Plus following clinical
validation.
64. DHS has stated that pregnant women will be assigned to the Healthy Plus package.
While women who are pregnant at the time of application are easily identifiable, as the Medicaid
application asks whether an applicant is pregnant, DHS has provided no process for current
Medicaid recipients to identify themselves as newly pregnant. Neither the “pre-transition letters”
nor the transition notices informed recipients that, if they become pregnant, they can be switched
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to Healthy Plus, nor did they tell recipients how to notify DHS of a pregnancy for this purpose.
As a result, women who are pregnant may be wrongly placed in, or remain in, the Healthy or
Healthy PA PCO categories.
Plaintiffs
65. On October 27, 2014, Plaintiff Melissa Mendez tripped and fell, fracturing her jaw,
breaking three teeth, and chipping a fourth tooth.
66. On October 28, 2014, Ms. Mendez went to the Temple University Dental School for
treatment. Dentists at the Dental School immediately sent her to the Temple University Hospital
emergency room, and called in additional doctors from Episcopal Hospital to help there. A team
of ten to twelve doctors from two hospitals worked together to treat her injuries, including wiring
her jaw shut.
67. On October 30, 2014, Ms. Mendez had surgery. She was discharged from Temple
University Hospital on October 31, 2014.
68. A social worker at Temple University Hospital filed a Medicaid application for Ms.
Mendez during her hospital stay. The application is still pending. On November 6, 2014, Ms.
Mendez filed a second Medicaid application on her own behalf.
69. Ms. Mendez was never given an opportunity to complete the health screening
questionnaire as part of these applications.
70. In early December 2014, Ms. Mendez was approved for GA-MA as a result of her
November 6, 2014 application. Just a few days later, she received a notice dated December 4,
2014, stating that she would be assigned to the Healthy PA PCO benefits package on January 1,
2015. The notice included an attachment showing that she would not receive dental coverage
through the Healthy PA PCO package.
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71. Ms. Mendez requires dental coverage to fix her three broken teeth and one chipped tooth.
The Healthy PA PCO benefits package is insufficient to meet those medical needs.
72. Plaintiff Aminata Diao is a mother of two with a history of physical and mental health
problems. Earlier this year, she suffered a bad fall and injured her back badly, rendering her
unable to work. She also suffers from asthma.
73. A few years ago, while struggling with homelessness, a history of domestic violence, and
severe sleep deprivation, she suffered a psychotic break in New York City while traveling home
from a visit with friends. She believed that people were communicating with her through their
computers and that she was speaking back to them telepathically. She was hospitalized for
several months at Bellevue Hospital in New York. She still suffers from depression.
74. Ms. Diao received a pre-transition letter in November 2014. She understood that she
would be moved to the Healthy benefits package on January 1, 2015, but did not understand that
she would face severe benefits cuts. She also did not understand that she should complete a
health screening questionnaire to receive a better benefits package.
75. On December 10, 2014 or December 11, 2014, Ms. Diao received a transition notice,
confirming that she would be assigned to the Healthy benefits package. The transition notice
was dated December 5, 2014 but postmarked December 9, 2014. The notice stated that Ms. Diao
must appeal by December 15, 2014, within six days of the mailing, to continue receiving her
current benefits package pending a fair hearing.
76. Because of her longstanding physical and mental health diagnoses, Ms. Diao appears to
meet DHS’s stated definition of medical frailty. The Healthy benefits package is insufficient to
meet her medical needs.
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CAUSES OF ACTION
Violations of the Due Process Clause of the Fourteenth Amendment – All Recipients
77. Defendants have assigned Medicaid and GA-MA recipients to the Healthy and Healthy
PA PCO benefits packages, with their markedly restricted benefits limits, using standards that are
not disclosed to recipients and applying three secret algorithms to determine their eligibility.
78. Defendants have failed to provide proper, individualized notice of Medicaid recipients’
and GA-MA recipients’ assignment into the Healthy and Healthy PA benefits package that
includes the specific reasons for their assignment and is supported by valid legal authority.
79. Defendants’ actions violate the Due Process Clause of the Fourteenth Amendment, and
are actionable pursuant to 42 U.S.C. § 1983.
Violation of the Social Security Act – First Subclass Only
80. Defendants have failed to provide proper, individualized notice of Medicaid recipients’
assignment into the Healthy benefits package that includes the specific reasons for their
assignment, provides notice and an opportunity to appeal and receive benefits pending fair
hearings ten days in advance, and is supported by valid legal authority.
81. Defendants’ actions violate the Social Security Act, 42 U.S.C. § 1396a(a)(3), and is
actionable pursuant to 42 U.S.C. § 1983.
PRAYER FOR RELIEF
WHEREFORE, Plaintiffs respectfully request that this Court:
(1)
Certify this action as a class action pursuant to Fed. R. Civ. P. 23(a), (b)(2), and
(c)(5) with respect to the proposed class and subclasses identified herein;
(2)
Declare the Defendants’ practices and policies pertaining to Medicaid and GA-
MA recipients assigned to the Healthy and Healthy PA PCO benefits packages invalid and
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unconstitutional under 42 U.S.C. § 1396a(a)(3), the Due Process Clause of the Fourteenth
Amendment to the United States Constitution, and 42 U.S.C. § 1983;
(3)
Enter preliminary and permanent injunctive relief, requiring the Defendants to:
(a)
Cease use of its three secret algorithms and health screening questionnaire
(b)
Cease moving existing Medicaid and GA-MA recipients from their
immediately;
existing benefits packages based on unascertainable standards and inadequate notice, or, in the
alternative, provide current Medicaid and GA-MA recipients with the planned Healthy Plus
benefits package, until such time as proper ascertainable standards and adequate and
individualized notice are in place; and
(4)
Award Plaintiffs their costs and reasonable attorneys’ fees; and
(5)
Provide such other and further relief as this Court deems just and proper.
Respectfully submitted,
/s/ Louise Hayes
Louise Hayes (ID No. 78581)
Electronic Signature # LEH8872
Amy E. Hirsch (ID No. 42724)
Community Legal Services
1410 West Erie Avenue
Philadelphia, PA 19140
(215) 227-2400
Kristen M. Dama (ID No. 207079)
Community Legal Services
1424 Chestnut Street
Philadelphia, PA 19102
(215) 981-3782
Jane Perkins
Sarah Somers
National Health Law Program
101 East Weaver Street, Suite G-7
19
Carrboro, NC 27510
(919) 968-6308
Attorneys for the Plaintiffs
Dated:
December 22, 2014
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Complaint Exhibit A
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Complaint Exhibit A
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Complaint Exhibit A
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Complaint Exhibit A
4 of 4
Complaint Exhibit B
1 of 4
Complaint Exhibit B
2 of 4
Complaint Exhibit B
3 of 4
Complaint Exhibit B
4 of 4
Complaint Exhibit C
1 of 4
Complaint Exhibit C
2 of 4
Complaint Exhibit C
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Complaint Exhibit C
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Health Care Needs Questionnaire
Please answer the following questions to the best of your knowledge. It is not required that you
complete this form. However, it is to your benefit to answer these questions because it will help us
identify what health care package best meets your individual needs. If you are uncomfortable
answering any portion of this questionnaire, then ignore the question and move to the next
question. All information you provide will remain confidential.
1.
In general, compared to other people your age, how would you rate your health?
(select only one)
a. Excellent
b. Very good
c. Good
d. Fair
e. Poor
2.
In general, compared to other people your age, how would you rate your mental health?
(select only one)
a. Excellent
b. Very good
c. Good
d. Fair
e. Poor
3.
Are you currently receiving services on a daily basis from family, friends, or an agency/paid
provider for each of the following activities? (answer each question)
YES
NO
Personal hygiene/grooming--such as brushing teeth, washing face, combing hair
Assistance walking or if you use a wheelchair, help once seated in chair
Help transferring from one place to another--such as moving from chair to bed,
chair to toilet or bed to standing position
Help eating -- Using a feeding tube or someone needing to feed you with a fork or
spoon
Managing medications--includes help with reminders to take medicines, opening
bottles, taking the correct dosage, giving injections
This document is for example purposes only.
Complaint Exhibit D
1 1 of 4
4.
In the last twelve months, how many times did you stay one or more nights in a hospital?
(do not count hospitalized for childbirth)
a. Not been hospitalized in the last twelve months
b. One time
c. Two times
d. Three or more times
5.
If hospitalized in the last twelve months, were any of these hospital stays related to mental
health issues?
a. Not hospitalized in last twelve months
b. None for mental health problem
c. One time for mental health problem
d. Two times for mental health problem
e. Three or more times for mental health problem
6.
In the last twelve months, how many times have you used an emergency room?
a. Not used emergency room in the last twelve months
b. One to two times
c. Three to five times
d. Greater than five times
7.
In the last twelve months, how many times have you been seen in an office or clinic by a
medical professional for a physical health or a mental health concern?
Bubble: (A ‘medical professional’ could be a doctor, nurse practitioner, physician assistant or
mental health professional.)
a. No visits in last twelve months
b. One to four times
c. Five to nine times
d. Ten or more times
This document is for example purposes only.
Complaint Exhibit D
2 2 of 4
8.
Has a doctor, nurse or medical professional ever diagnosed or treated you for concerns of
any of the following:
a. Never diagnosed
b. Alcohol
c. Street Drugs
d. Prescription Medication Use
9.
Are you concerned about your use of alcohol or drugs? Y/N
Bubble: (If you are uncomfortable answering any portion of this questionnaire, then ignore the
question and move to the next question.)
10. Is a friend, relative or anyone else concerned about your use of alcohol or drugs? Y/N
Bubble: (If you are uncomfortable answering any portion of this questionnaire, then ignore the
question and move to the next question.)
11. How many medications is your doctor currently directing you to take?
Count each bottle of medication only once, even if you take it often.
Include inhalers and liquids. Do not count over-the-counter (non-prescription) medications?
a. Not taking any medications at this time.
b. Currently taking one to three medications.
c. Currently taking four to eight medications.
d. Currently taking more than eight medications.
12. My height is: _________ feet and ___ inches
My weight is: _________ pounds
This document is for example purposes only.
Complaint Exhibit D
3 3 of 4
13. Has a doctor, nurse, or other medical professional EVER told you that you had any of the
following? For each, select “Yes,” “No,” or you’re “Not sure.”
bubble: (A ‘medical professional’ could be a doctor, nurse practitioner, physician assistant or
mental health professional.)
bubble: (Do not be concerned if you have not heard of a condition on this list. Just check ‘Don’t
Know/Not Sure”)
YES
NO Don’t Know
/ Not Sure
Cancer
ALS or muscular dystrophy
Asthma
Autism
Bipolar disorder
Bleeding disease (hemophilia)
Cystic fibrosis
Depression
Diabetes
Emphysema/COPD
Heart attack
Heart failure or Heart transplant
HIV or AIDS or Other immune deficiency
Intellectual disability (previously called mental retardation)
Kidney failure, transplant or dialysis
Leukemia
Liver failure/cirrhosis or Liver transplant
Lung (pulmonary) hypertension
Lung transplant
Multiple sclerosis
Obsessive Compulsive Disorder
Pancreas and/or small bowel transplant
Panic Disorder
Peritonitis
Post Traumatic Stress Disorder
Psychotic disorder
Quadriplegia or paraplegia
Schizophrenia or Schizoaffective Disorder
Severe joint or back pain or Lupus
Sickle cell disease
Skin ulcers/wounds
Stroke
Substance use disorder
Tracheostomy or ventilator
Ulcerative colitis/Crohn’s disease
14. Please provide the name of the most recent physician office/clinic that you have visited,
along with the city or county location:
Physician or Clinic Name: _________________________________
City or County: _________________________________________
Complaint Exhibit D
4 4 of 4
Notice ID:
Mail Date: 11/27/2014
OFFICE OF INCOME MAINTENANCE
Record ID:
Telephone:
Notice ID:
COMPASS: The fast and easy way to apply for benefits
www.compass.state.pa.us
Pennsylvania receives information from other state and federal agencies to verify the information you
give them. If you misrepresent, hide, or withhold facts which may affect your eligibility for benefits, you
may be required to repay your benefits, and you may be prosecuted and disqualified from receiving
certain future benefits.
DEAR
The Commonwealth of Pennsylvania has added a new benefit plan, the Healthy Pennsylvania Private
Coverage Option, and made some changes to the current Medical Assistance benefit plans.
This is a summary of your benefits.
Which benefit?
You can find more information inside this letter.
There are changes to the health care coverage for one or
more members of your household.
Healthy PA Private Coverage
Option
One or more members of your household qualify for Healthy
PA Private Coverage Option benefits starting January
01, 2015.
If you do not agree with this decision, fill out the enclosed Fair Hearing form, then mail it or give it to your
caseworker by December 27, 2014. If we get the form on or before December 07, 2014, you will continue
to receive your benefits while you wait for the Fair Hearing decision.
Children under age 21 are not affected by this transition and continue to be eligible for the same services.
Additionally, Healthy PA has no effect on other benefits your household may be receiving, such as SNAP,
LIHEAP or cash benefits.
If you have a disability and need this letter in large print or another format,
please call our helpline at 1-800-692-7462. TDD Services are available at
1-800-451-5886.
If you do not agree with our decision, you have the right to a Fair Hearing. To learn more about Fair
Hearings, read Your Right to Appeal and to a Fair Hearing.
Do you need legal help? You can get free legal help by visiting:
Record ID:
Page 1 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
*
*900076057630000106*
Medical Assistance
1 of 20
Notice ID:
Your Medical Assistance Benefits
Who qualifies?
Who?
When?
Which package?
Starting Jan 01, 2015
Healthy Plus
:(Starting Jan 01, 2015) You continue to be eligible for health care coverage, however there
may be some new service limitations.
This is the law we used to make this decision:42 CFR § 435.603, 55 Pa. Code § 141.71, 62 P.S. §§
201(2), 403(b), Healthy PA 1115 waiver.
You will receive the Healthy Plus benefit package, effective 01/01/2015, based on your permanent
disability, pregnancy or need for long-term care or waiver services. For a list of services offered in this
benefit package and their limits, refer to the enclosed benefit comparison chart insert.
If you would rather receive the Healthy benefit package instead of the Healthy Plus benefit package
because you think you do not need extensive medical services, contact the Statewide Customer Service
Center at 1-877-395-8930, or 1-215-560-7226 (if you live in Philadelphia) by 12/13/2014.
Who no longer qualifies?
Who?
When?
Starting Jan 01, 2015
:(Starting Jan 01, 2015) Effective December 31, 2014, the Medical Assistance program that you
are currently enrolled in has been discontinued. You will continue to receive your benefits until
December 31, 2014. Based on the information in your records, you qualify for Healthy PA Private
Coverage Option. See later in this notice for more details.
This is the law we used to make this decision:42 CFR § 435.603, 55 Pa. Code § 141.71, 62 P.S. §§
201(2), 403(b), Healthy PA 1115 waiver.
Eligibility for Medical Assistance transportation ends on the day your medical assistance eligibility ends.
This is the law we used to make this decision: 55 Pa. Code § 2070.41(c), 62 P.S. §§ 201(2), 403(b),
Healthy PA 1115 waiver.
Record ID:
Page 2 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
2 of 20
Notice ID:
Your Healthy PA Private Coverage Option Benefits
Who qualifies?
Who?
When?
Starting Jan 01, 2015
Which package?
Healthy PA Private Coverage
Option
Each family member eligible for Healthy PA Private Coverage Option must choose a Health Plan. If you
do not choose a plan, you will be assigned to one. To enroll or get more information, call
1-844-465-8137.
:(Starting Jan 01, 2015) You continue to be eligible for health care coverage, however the
services that you may receive have changed.
This is the law we used to make this decision:42 CFR § 435.603, 55 Pa. Code § 141.71, 62 P.S. §§
201(2), 403(b), Healthy PA 1115 waiver.
If you have any change in a medical condition and you believe the Healthy PA Private Coverage Option
benefit plan will not meet your needs contact the Statewide Customer Service Center at
1-877-395-8930, or 1-215-560-7226 (if you live in Philadelphia) at any time or contact your local County
Assistance Office.
Record ID:
Page 3 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
*
*900076057630000206*
You will receive the Healthy PA Private Coverage Option plan, effective 01/01/2015, based on the
information we have in your record. Your record may include medical assistance claims data reviews,
your health screening results, your medical assistance category and other case information. The
information we have indicates that you are a 21 to 64 year old adult; or a 21 to 64 year old
parent/caretaker of a child under 19 with income over 33 percent of the Federal Poverty Level. The
information also indicates that you are not permanently disabled, pregnant or suffering from a condition
such as a disabling mental disorder; an active chronic substance abuse disorder; a serious and complex
medical condition; or a physical, intellectual or developmental disability that significantly impairs your
functioning. For a list of services offered in this benefit package and their limits, refer to the enclosed
benefit comparison chart insert.
3 of 20
Notice ID:
Record ID:
Page 4 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
4 of 20
Notice ID:
Do you need help
with your phone bill?
If you get any of these:
Supplemental Nutrition Assistance Program,SNAP;
Cash Assistance;
Medical Assistance, MA;
Healthy Pennsylvania Private Coverage Option;
National School Free Lunch Program;
Federal Public Housing Assistance;
Supplemental Security Income, SSI; or,
Low Income Home Energy Assistance Program, LIHEAP,
Most phone companies in Pennsylvania provide Lifeline
service. These programs lower your phone costs for one
phone line. Verizon and Verizon North customers can get
Lifeline or Lifeline 135. All other customers get Lifeline 135.
Start
saving today!
See the other side of this flier for a Lifeline form.
www.dpw.state.pa.us
PA 1799 SG 3/12
Record ID:
Page 5 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
*
*900076057630000306*
you may also be able to get
Lifeline or Lifeline 135.
5 of 20
Notice ID:
Pennsylvania Telephone Companies Offering Lifeline Service
Find your local phone company listed below and mail in your form today. For faster service, call your local phone company
directly to enroll. To find the local phone company for your county, please visit the Public Utility Commission’s web site at
www.puc.state.pa.us
Armstrong Tel. Company NORTH
693 Main Street, P.O. Box 342
Duke Center, PA 16729
814-966-3207
Hancock Telephone Co.
P.O. Box 608
Hancock, NY 13783
607-637-9911
Palmerton Telephone Company
P.O. Box 215
Palmerton, PA 18071
610-826-2115
Armstrong Tel. Company - PA*
1755 State Route 30
Clinton, PA 15026-0418
724-899-2211
Hickory Telephone Co.
75 Main Street
Hickory,PA 15340-1118
724-356-2211
Pennsylvania Telephone Company*
191 Middle Road
Jersey Shore, PA 17740
570-745-7101
*only serves 570 area code/745 prefix
Verizon Lifeline Service- PA
P.O. Box 33075
St. Petersburg, FL 33733-8075
1-800-VERIZON
1-800-837-4966
CenturyLINK
(Formerly known as Embarq)
P.O. Box 7086
London, KY 40742
1-800-829-8009
Ironton Telephone Company
4242 Mauch Chunk Road
Coplay, PA 18037
610-799-3131
Pymatuning Independent Tel. Co.
5 Edgewood Drive
Greenville, PA 16125
724-646-5400
West Side Telecommunications
1449 Fairmont Road
Morgantown, WV 26501
1-800-296-9113
Citizens Telephone Co. of
Kecksburg
P.O. Box 156
Mammoth, PA 15664
724-423-4444
Lackawaxen Telephone
Company
P.O. Box 8, Route 590
Rowland, PA 18457
570-685-7111
RCN Quality Assurance
Must be faxed to:
570-270-1322
Consolidated Communications
4008 Gibsonia Road
Gibsonia, PA 15044-0395
724-443-9521
Laurel Highland Telephone Co.
P.O. Box 168
Stahlstown, PA 15687
724-455-2411
Service Electric Telephone
4242 Mauch Chunk Road
Coplay, PA 18037
610-841-4100
Fairpoint Communications
Must call:
1-800-400-5568
North Penn Telephone Co.
4145 State Route 549
Mansfield, PA 16933
570-549-3705
South Canaan Telephone Co.
P.O. Box 160
South Canaan, PA 18459
570-937-4114
Frontier Communications
39 Public Square, P.O Box 5900
Wilkes-Barre, PA 18773-5900
800-225-5282
Northeastern PA Telephone Co.
720 Main Street, P.O. Box D
Forest City, PA 18421-0150
570-785-3131
TDS Telecom - Lifeline
P.O. Box 608
Lancaster, WI 53813
1-888-837-1347
Toll Free Fax: 1-877-271-2861
*for customers living in Clinton, PA only
Venus Telephone Corporation
County Line Road, Box 75
Venus, PA 16364
814-354-2192
Windstream
ATTN: Support Services -Lifeline
1720 Gallieria Blvd.
Charlotte NC 28270
800-347-1991
FAX: 707-849-7000
Yukon Waltz Telephone Co.
P.O. Box 398
Yukon, PA 15698-0398
724-722-3131
Lifeline Enrollment Form
Please print the name and address of the person applying for Lifeline Service.
Date
/
Last Name
First Name
Middle Initial
Street/Apartment No.
City
State
County
Telephone Number
(
)
/
Zip Code
Name of Telephone Company (if known)
Signature of Applicant
I understand that my telephone company may contact me for information to qualify for Lifeline.
PA 1799 SG 3/12
Record ID:
Page 6 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
6 of 20
Notice ID:
If you have any questions about this notice...
You should take time to review this notice for accuracy.
If you have questions about this notice or your benefits, you can call the Statewide Customer Service Center at
1-877-395-8930.
In Philadelphia, call 1-215-560-7226.
The call is free. Call Monday through Friday between 8 a.m. and 5 p.m.
If you do not agree with this decision...
Your Right to Appeal and to a Fair Hearing
What does right to appeal mean?
Your right to appeal means that you have the right to ask us to review our decision, if you think that we made a
mistake. You can ask a judge to review the county assistance office's (CAO) decision at a fair hearing.
What is a fair hearing?
A fair hearing is a formal meeting where you, the CAO and a judge can talk about your appeal. The judge will follow
the law and the department's policies in making a decision. You should be prepared for the meeting. If you want to
present any evidence that supports your claim that the decision was not correct, bring that evidence with you.
How can you ask for a fair hearing?
• Call the CAO to ask for a fair hearing, and
• Mail the completed, attached Fair Hearing Form to the CAO or
• Take the completed, attached Fair Hearing Form to the CAO.
Note: You do not have to complete the Fair Hearing Form if the decision is for SNAP (Food Stamps), but it's easier
for us to track your appeal if you do.
Do you need legal help?
You can ask for free legal help by visiting Legal Services at
1. If you want to appeal our decision, fill out and sign the Fair Hearing form included in this
packet.
2. Choose the kind of fair hearing you want:
• A telephone hearing at a place you choose. Tell us which phone number to use, such as your
own, or a friend or relative’s phone number. If you choose this kind of hearing, make sure we
can reach you at this phone number.
The judge will call you, your witnesses, anyone helping you, and the CAO.
• A telephone hearing at the CAO. You will go to the CAO for your hearing.
The judge will call you there in the office, and call anyone helping you.
• A face-to-face hearing with you and the people you bring in the hearing room with a judge and
CAO staff on the phone.
You and anyone helping you will be in the hearing room with a judge. The CAO staff will be
on the phone.
You must travel to the assigned Bureau of Hearings and Appeals office for a face-to-face
hearing. The location will be assigned to you based on where you live.
• A face-to-face hearing with you and the people you bring in the hearing room with you with a
judge and the CAO staff in the hearing room.
The judge, you, CAO staff, witnesses and anyone helping you will be in the room.
You must travel to the assigned Bureau of Hearings and Appeals office for a face-to-face
hearing. The location will be assigned to you based on where you live.
*900076057630000406*
If you want to file an appeal and ask for a Fair Hearing...
PA/FS 162 F 7/14
Record ID:
Page 7 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
**
7 of 20
m
for
et
giv
r
o
Notice ID:
3. Mail the form to:
a.
b.
c.
For Cash Assistance, Health Care, LIHEAP or SSP, you must mail or give the form to the CAO within
30 days of the mailing date on your letter.
If you are applying for SNAP and you do not agree with the decision, you must mail, or give the form to
the CAO within 90 days of the mailing date on your letter.
If you already get SNAP and you do not agree with the decision, you must mail, call or give the form to
the CAO within 90 days of the first day of the month that your benefits change.
Reminder: You may continue to receive your benefits while you wait for your fair hearing if:
1.
This letter tells you that your benefits will stop or be reduced; and
• This letter provides you a date to request an appeal and to continue your benefits while you wait
for the Fair Hearing Decision; and
• Your request for appeal is received or postmarked by that date and you do not waive
continuation of benefits; OR
2.
This letter tells you that your benefits will stop or be reduced; and
• The reason for this change is because of information you provided on a semiannual reporting
form; and
• Your request for appeal is received or postmarked within 10 days of the mailing date on this
letter and you do not waive continuation of benefits.
Get ready for a hearing...
Can you talk with us before the fair hearing?
Yes. You will get a letter from the CAO asking if you want to meet before the fair hearing takes place. A meeting
before the hearing is called a pre-hearing conference. This meeting will not delay or replace your fair hearing.
You can use this meeting to tell us if you have information that you think might change our decision. You can
bring someone to speak for you if you want to.
Can you get a copy of any information we used to make our decision?
Yes, you can ask for a copy of all the documents that will be used at the hearing.
Who can come to the hearing?
You can bring anyone to the hearing, such as witnesses who might have information. You can speak for yourself
or bring someone to speak for you who knows more about the rules of the program.
What if you speak another language, are deaf or have another disability?
You can ask for an interpreter to be at the fair hearing, or other assistance, on the attached Fair Hearing Form.
This is a free service. You may bring a friend or relative to help you at the hearing, but the department will
provide the official interpreter.
At the hearing...
What happens at a fair hearing?
You will have time to tell the judge your side of the case. Someone can speak for you (if you want), and your
witnesses can speak. You may show documents to the judge.
When will you know what the judge decides?
The judge will send you the decision within 90 days (within 60 days for SNAP) of the day you asked
for the hearing.
You may have to pay back some or all of the benefits you got while waiting for your hearing.
What happens if the judge decides the CAO is right?
If the judge decides that the CAO made the right decision, your benefits will change or stop.
You may have to pay back some or all of the benefits you got while waiting for your hearing.
What if you do not agree with the judge’s decision?
You can appeal again. The judge’s decision letter will tell you how to appeal.
Record ID:
Page 8 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
8 of 20
Notice ID:
Fair Hearing Form
Case Number:
1. Name:
Address:
Phone number:
2. Tell us which program you want to appeal:
Medical Assistance
Healthy PA Private Coverage Option
3. Do you want your SNAP benefits to continue at the same amount pending the hearing
Yes
No
decision?
4. Choose the way you want your hearing:
By telephone, at the phone number you write on this form.
By telephone, at the CAO.
Face-to-face, with you and the people you bring in the hearing room with a judge
and CAO staff on the phone.
Face-to-face, with you and the people you bring in the hearing room with a judge
and CAO staff in the hearing room.
Reminder: You must travel to the assigned Bureau of Hearings and Appeals office for a face-to-face
hearing. The location will be assigned to you based on where you live.
5. Do you need a free interpreter?
Yes
No
If yes, what language? ______________________________________________________
6. If you will need help at the appeal because of a hearing impairment or other disability,
please tell us how we can help you. There is no cost to you for this service.
___________________________________________________________________________
___________________________________________________________________________
7. Tell us why you disagree with this decision:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
8. Signature: __________________________________________
9. Date: _______________________________________________
If someone will be helping you with your appeal, please fill out the information for the
representative below.
9. Representative Name: ________________________________
10. Representative Address: ____________________________________________________
11. Representative Telephone Number: ___________________________
The Bureau of Hearings and Appeals will send you a letter to tell you when and where
your hearing will be.
*900076057630000506*
___________________________________________________________________________
PA/FS 162 F 7/14
Record ID:
Page 9 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
*
9 of 20
Notice ID:
Record ID:
Page 10 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
10 of 20
Notice ID:
Welcome
•
Be sure to carry your ACCESS card with you at all times. When you go to get health care services,
please show all of your insurance cards, including your ACCESS card.
•
If you need a new ACCESS card, call: 1-877-395-8930. If you live in Philadelphia, call: 1-215-5607226.
•
There is a limit to the number of visits and services you can get. Please talk with your provider or call
1-800-537-8862, Option #2, #3, #2 about these limits. If you need services that exceed the limit, you
or your doctor may request a benefit limit exception.
•
For more information about what is included in these services, call: 1-800-537-8862, Option #2, #3,
#2.
•
If you are enrolled in a HealthChoices Managed Care Organization please check with the plan since
they may provide additional services above those required by the Medical Assistance program.
•
Please note that if your household income is above 100% of the Federal Poverty Limit, your MA
provider may refuse service if you fail to pay any copayments, but only as long as refusing service due
to failure to pay copayments is standard practice for that MA provider.
•
If you are subject to cost sharing, you can reduce your cost sharing, starting January 1, 2016, by
completing Healthy Behaviors throughout calendar year 2015. Healthy Behaviors include the paying of
cost sharing at the point of service (doctor office, hospital, etc.) and completing an annual wellness
exam at your primary care physician before October 31, 2015. The Department of Public Welfare will
automatically track completion of these Healthy Behaviors.
Here are some helpful tips on using Private Option Coverage (PCO):
•
Be sure to carry your PCO card with you at all times. When you go to get health care
services, please show all of your insurance cards, including your PCO card.
•
If you need a new PCO card, please contact your PCO.
•
There is a limit to the number of visits and services you can get. Please talk with your
PCO about these limits. For more information about what is included in these services,
call your PCO.
•
•
Please note that if your household income is above 100% of the Federal Poverty Limit,
your Private Coverage Option provider may refuse service if you fail to pay any
copayments, but only as long as refusing service due to failure to pay copayments is
standard practice for that Private Coverage Option provider.
If you are subject to cost sharing, you can reduce your cost sharing, starting January 1,
2016, by completing Healthy Behaviors throughout calendar year 2015. Healthy
Behaviors include the paying of cost sharing at the point of service (doctor office, hospital,
etc.) and completing an annual wellness exam at your primary care physician before
October 31, 2015. The Department of Public Welfare will automatically track completion of
these Healthy Behaviors.
Record ID:
Page 11 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
**
*900076057630000606*
Here are some helpful tips on using Medical Assistance (those eligible for the Healthy or
Healthy Plus Benefit Plan):
11 of 20
Notice ID:
BENEFIT PLAN COMPARISON CHART
You may get these services:
Healthy Plan
Healthy Plus Plan
PCO Plan
Ambulance Services
(emergency)
Ambulatory surgical centers
(ASCs)
CRNP
Clozapine
Crisis support
Chiropractic services
Dental services
Durable medical equipment
Emergency services
Eyeglasses/contact lenses
No limits
No Limits
No Limits
2 visits per Calendar Year (CY)
No Limits
No Limits
Laboratory tests
Federally qualified health
center/rural health clinic
Family Planning
Home health care
Hospice Care
Independent Clinic
Inpatient drug and alcohol
Inpatient acute hospital
Inpatient rehabilitation hospital
Inpatient psychiatric hospital
Intermediate care facility
(IID/ORC)
Maternity Services
Mobile mental health treatment
Medical supplies
Methadone Maintenance
Nutritional supplements
Optometrist services
Outpatient drug and alcohol
services
Outpatient hospital clinic
Outpatient psychiatric clinic
Peer support
Physician Office visits
Podiatrist services
Prescription drugs
Primary care provider
Psychiatric partial hospital
Radiology (X-rays, MRI’s, CT’s)
Renal dialysis (kidney
treatment)
Residential Treatment Facility
(Non-Hospital Residential D&A)
Short Procedure Unit (SPU)
Skilled nursing facility
Transportation help
3 visits per CY
Limited to Schizophrenia (1 per wk)
No Limits
9 visits per CY
Covered *
$1000 per CY
No Limits
Limited to individuals with aphakia
2 eyeglass frames per CY
4 eyeglass lenses per CY
4 contact lenses per CY
$350 per CY
No Limits (except for dental service as
defined above)
No Limits
60 visits per CY
No Limits
No Limits
No Limits
10 visits per CY
Covered *
No Limits
No Limits
Limited to individuals with aphakia
2 eyeglass frames per CY
4 eyeglass lenses per CY
4 contact lenses per CY
No Limits
No Limits (except for dental services as
defined above)
No Limits
Unlimited first 28 days; 15 days per
month following.
No Limits
No Limits
Respite care may not exceed a total of 5 Respite care may not exceed a total of 5
days in a 60-day certification period.
days in a 60-day certification period.
5 visits per CY
No Limits
30 days per CY
No Limits
2 non-emergency admissions per CY
No Limits
1 admission per CY
No Limits
30 days per CY
No Limits
NOT COVERED
No Limits
No Limits
No Limits
No Limits
20 visits per CY
NOT COVERED**
No Limits
No Limits
NOT COVERED**
No Limits
31 visits per CY
$1000 per CY
No Limits
No Limits
$2500 per CY –does not include
diabetic supplies when provided by a
pharmacy
No Limits
No Limits
1 visit per CY
No Limits
No Limits
NOT COVERED**
NOT COVERED** (diabetic
supplies provided by a
pharmacy is covered)
No Limits
NOT COVERED**
1 visit per every 2 CYs
No Limits
No Limits
No Limits
No Limits
No Limits
No Limits
No Limits
No Limits
No Limits
No Limits
Initial training for home dialysis is limited
to 24 sessions per patient per CY.
Backup visits to the facility limited to no
more than 75 per CY
No Limits
No Limits
No Limits
NOT COVERED**
No Limits
No Limits
No Limits
No Limits
No Limits
No Limits
NOT COVERED**
No Limits
No Limits
Available to and from a MA covered
service
70 visits per CY
30 visits per CY combined for PT/OT 30
visits per CY for ST
No Limits
120 days per CY***
NOT COVERED**
One visit per day/7 visits per week
No Limits
1 visit per CY
Opiate Detox: 42 visits per CY
Chemotherapy/drug-free visits: 3 visits
per 30 days
9 visits per CY
30 visits per CY
4 hours per day/ 900 hours per CY
4 visits per CY
4 visits per CY
6 prescriptions per month
No Limits
540 hours per CY
6 tests per CY
Initial training for home dialysis is limited
to 24 sessions per patient per CY.
Backup visits to the facility limited to no
more than 75 per CY
NOT COVERED
5 visits per CY
No Limits
Available to and from a MA covered
service
Tobacco cessation
70 visits per CY
Therapy (physical, occupational, Only when provided in a hospital,
speech (PT, OT, ST)) (includes
outpatient clinic, or home health
rehabilitative and habilitative)
provider.
Targeted Case Management
NOT COVERED
(Behavioral Health)
Targeted case management
Available only to individuals within the
(other than Behavior Health)
target group (No Limits)
Available to individuals with a diagnosis
of Serious Mental Illness (No Limits)
Available only to individuals within the
target group (No Limits)
No Limits
No Limits
No Limits
60 visits per CY
No limits
Respite care is not provided.
No Limits
No Limits
No Limits
No Limits
No Limits
NOT COVERED**
No Limits
NOT COVERED**
30 visits per CY combined for
PT/OT
30 visits per CY for ST
NOT COVERED**
NOT COVERED**
* More detailed benefit information is available on the Healthy PA website: www.healthypa.com
** PCO plans may opt to cover these services; please refer to your specific plan’s benefit documents for coverage details.
*** Individuals in the PCO plan that are determined to require more than 120 days of skilled nursing facility care will be
evaluated for eligibility for the Healthy Plus Plan and be eligible for unlimited coverage of skilled nursing facility care.
Record ID:
Page 12 of 12
Mail Date: 11/27/2014
Complaint Exhibit E
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