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Court Says Medicaid Coverage Gap Must End, Seniors No Longer on the Hook for Thousands in Assisted Living Bills

September 3, 2015

Ohio’s Medicaid program covered only a portion of the program’s assisted living bills, leaving frail seniors Betty Hilleger and Geraldine Saunders with unexpected sky-high expenses. And they were not alone. Thousands of Ohio’s seniors faced the same coverage gap. They applied for coverage, but faced delays and unreasonable bills even after they were supposed to be covered. Justice in Aging joined with the Cincinnati firm Beckman Weil Shepardson to represent Hilleger and Saunders in a class action suit against the state to eliminate this coverage gap.

On September 1, a Cincinnati federal court found that Ohio’s practices violated federal Medicaid laws which require coverage up to three months prior to the month of application for Medicaid services, if all eligibility requirements are met. This is the same rule that governs other Medicaid-eligible expenses such as health care and nursing facility stays. The laws surrounding assisted living in Medicaid were designed to save money and improve lives by giving recipients real options instead of funneling them into nursing facilities.

Ohio’s Medicaid consumers were following the rules, but were still getting hit with huge bills that should have been covered by Medicaid. Ohio argued that consumers had to pay these bills, using improper federal policy and guidance as support for its practices. This led to consumers remaining in nursing facilities longer than necessary or facing eviction from their homes in assisted living. But the court found that the law itself is clear: Medicaid-eligible assisted living should not have a coverage gap.

Because of the improper federal guidance, Ohio is not alone in getting it wrong. Many states that offer Medicaid-eligible assisted living also have this illegal coverage gap. This Ohio case should serve as a wake-up call for these states, and for the federal Medicaid agency as well, to clean up their acts and give consumers the coverage the law requires. Nationwide, low-income seniors must receive the full protection of the law, not bureaucratic delays and thousands of dollars in bills they cannot afford.

The press release is available here. The full court order can be accessed here.

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