Decisions

SUSTAINED APPEALS
(click on appeals to download)


The First Medicaid-Funded Whole-House Generator
(from denial to installation of liquid-cooled model)

  1. Original request: November 2005
  2. I was told, “Medicaid never pays for generators, and never will.”
  3. Approval: May 2006
  4. Air-cooled model offered… an inadequate type I declined.
  5. I was told, “No one wins Medicaid cases against the state in court.”
  6. Judicial appeal sustained for liquid-cooled model: September 2007
  7. Liquid-cooled model ordered: October 2007
  8. Installation: May 19, 2008

APPEAL #1259473 Decision Date: 1/13/2006, SUSTAINED (without immediate approval of a generator)

  • This appeal was for a whole-house generator and a ramp/deck. I withdrew my appeal for the ramp/deck.
  • Carestar and the hearing officer treated the generator as an adaptive/assistive device, with Carestar claiming it was not such a device.
  • The hearing officer acknowledged my previous small gasoline-powered generator that caught fire as a possible safety hazard.
  • Carestar offered to help with a back-up plan in case of an emergency; such plans required me to be moved to a medical facility in case of such an emergency.
  • Ignoring Carestar’s back-up plan – possibly because such a plan would not keep me in the community – the hearing officer wrote, “It seem reasonable to this Hearing Officer that some type of device is needed.”
  • “Therefore this Hearing Officer judges the actions of the Agency in denying the Appellant request for a 20KW natural gas-powered generator without investigating the lowest cost alternative to address the medical problem to be inappropriate.”

ADMINISTRATIVE APPEAL #2006-AA-0099 Request Date: 1/30/2006

  • Not believing that Carestar would comply within thirty days, I filed an administrative appeal to clarify the decision.
  • The administrative appeal officer claimed my request was, “more in the vein of an ‘emergency response system…’” instead of a generator.
  • The administrative appeals officer AFFIRMED the hearing officer’s decision, but also ordered Carestar to look into an emergency response system.
  • The administrative appeals officer requested a hearing for an “application for home modification for an emergency exit” while I retain “all state hearing rights regarding any future agency determination.”

APPEAL #1274905 Decision Date: 5/11/2006, SUSTAINED

  • This appeal was for a whole-house generator – because Carestar would only provide an emergency back-up plan for power outages – and an emergency exit from my room. (Only the emergency exit was overruled.)
  • This hearing officer interpreted “emergency response system” as an “analogy” for a “back-up generator.” (NOTE: The initial hearing officer ordered “that some type of device is needed,” and NOT a back-up plan.)
  • This hearing officer dismissed Carestar’s back-up plans due to the extensive list of medically-necessary items without proper battery back-up, frequent power outages, my small gasoline-powered generator that caught fire and that, “the Carestar emergency plan calls for admitting the Appellant to a nursing facility, something that the OHC waiver is intended to avoid.”
  • This hearing officer wrote, “Without a continuous supply of electricity, the Appellant will suffer increased morbidity or death. Medical necessity is clearly established.”
  • This hearing officer wrote, “A review of the evidence and of the Medicaid regulations shows that the Appellant’s request meets the requirements of medical necessity and of the home modification rule. Carestar’s denial of the request was incorrect.”
  • This hearing officer wrote, “Carestar should be directed to determine the lowest cost natural gas or propane powered generator that will meet the minimum power needs to assure the Appellant’s health and safety, and proceed with acquisition and installation.”

ADMINISTRATIVE APPEAL #2006-AA-0511 Request Date: 5/26/2006

  • This administrative appeal for the whole-house generator was initiated because Carestar was delaying compliance with the hearing officer’s orders.
  • Carestar was also, “attempting to circumvent the hearing officer’s ruling by only powering what they call ‘medical equipment only,’ even though the central furnace was stipulated as an example by the hearing officer.”
  • The administrative appeal officer in this case expressed dissatisfaction with the hearing officer’s decision, but begrudgingly remarked that his decision stands.
  • Although the administrative appeal officer said I should take my case to the Columbus Hearings Supervisor, any disagreement I have with Carestar “can be the subject of a further state hearing, if need be.”

APPEAL #1304888 Decision Date: 11/6/2006, SUSTAINED

  • Carestar claimed I requested a whole-house generator that was above the cost cap, while in reality, I requested Carestar to consider two generators; one of which fell under the cost cap.
  • Carestar attempted to approve and install a generator that failed to provide an adequate amount of power for my medically-necessary equipment.
  • I refused the installation of an air-cooled generator, because it required a shut-down period of one hour every 24 hours. (Carestar falsely claimed that the shut-down period was only 15 minutes every 24 hours.)
  • The hearing officer was presented with evidence that disputed Carestar’s claims and sustained my appeal.
  • The hearing officer cited that the generator I presented did, in fact, fall under the cost cap.

ADMINISTRATIVE APPEAL #AA-1015 Request Date: 3/28/2007

  • This administrative appeal was filed because Carestar again denied the installation of a generator that provided enough power for my medically-necessary equipment.
  • I provided a quote for a generator designed explicitly for life-support equipment which fell above the cost cap. Carestar refused to split the cost into two yearly cost caps.
  • I provided a quote for another generator that was liquid-cooled – one without the need for a shut-down period – which fell below the yearly cost cap.
  • Both Carestar and the administrative appeal officer ignored the alternative generator completely, and denied my rights to a fair appeal. (The administrative appeal officer neglected to sign his/her name to the decision; 4/11/2007.)
  • I was forced to file a judicial appeal.

JUDICIAL APPEAL, Case No. 07CV-6376
IN THE COURT OF COMMON PLEAS, FRANKLIN COUNTY, OHIO, CIVIL DIVISION 9/21/2007

  • Appellant’s Brief
  • State’s Response Brief
  • Appellant’s Reply Brief
  • The court found that Carestar and the Ohio Department of Jobs and Family Services (ODJFS) intentionally ignored the whole-house liquid-cooled generator that fell below the yearly cost cap.
  • Because “the agency” is missing evidence, and cannot prove they considered the alternative generator, the Court “finds that the failure constitutes an error which requires a remand to the agency for further consideration.”

Carestar was forced to provide the alternative generator. See the official approval here.

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