Federal Court Orders Ohio Medicaid Program to Eliminate Coverage Gap For Low-Income Assisted Living Residents - Ruling Has National Implications

Cincinnati, OH—Under a ruling Tuesday from a Cincinnati federal court, the Ohio Medicaid program must eliminate a coverage gap that has saddled many Ohio assisted living residents with hundreds or thousands of dollars of unaffordable assisted living charges. The class-action case was brought by Betty Hilleger and Geraldine Saunders, frail seniors who were denied complete coverage when enrolling in Ohio's Assisted Living Waiver program.

The court ruled that Ohio's practices violate a federal Medicaid law that requires coverage up to three months prior to the month of application, if all eligibility requirements are met. Ohio honors this three-month rule for most services, including nursing home services, but covers assisted living services only prospectively from when program employees complete certain post-application logistical steps.

The plaintiffs were represented by Cincinnati firm Beckman Weil Shepardson and national advocacy group Justice in Aging. “This decision is a triumph for our plaintiffs and for the whole class. Thousands of vulnerable people have been impacted by Ohio’s practices over the years, either because they were billed for care that they could not afford or they were trapped in hospitals or nursing homes for no reason. This decision helps frail and needy Ohio elders to get coverage for the care they need in assisted living facilities,” said Janet Pecquet, an attorney at Beckman Weil Shepardson LLP.

Ohio's actions were based in part on federal Medicaid procedures that limit coverage for assisted living services and other types of long-term care provided outside of nursing homes. Those federal procedures, along with the coverage limitations of many states other than Ohio, are called into question by the court's ruling.

"The court's ruling is an important development for low-income elders across the country who want to be able to receive necessary services without moving into a nursing home," said Justice in Aging attorney Eric Carlson. "This ruling should be a wake-up call for federal and state Medicaid officials to reform their policies and eliminate these nonsensical coverage gaps."

The full court order can be accessed here.