Class Action Lawsuit Filed to Improve Access to Wrap-Around Services

On June 25th, 1999 seven children in Pennsylvania filed a class action lawsuit against the Secretary of the Department of Public Welfare, the state agency that is responsible for providing Medicaid funded services. The children claim that they, and numerous other children across the state, have waited many months and sometimes more than a year for needed Behavioral Health Rehabilitation services (BHR services, often called wrap-around services) that have been prescribed for them. They claim that the Secretary's failure to assure the prompt provision of needed services violates federal law. The suit, filed in federal district court in the Eastern District of Pennsylvania, is called Kirk T. v. Houstoun.

Kirk T., from Philadelphia, has severe depression since he lost his father last year, has attempted suicide more than once and has been in and out of psychiatric hospitals while waiting for the BHR services that were considered necessary and authorized for him many months ago. Another plaintiff, Dillon S., from Montgomery County, had waited almost two years for services to treat his autism. William P., a 20 year old from Lackawanna County who has bi-polar disorder with psychosis in remission, and mild mental retardation, was walking the streets aimlessly in the evenings instead of engaging in the structured, therapeutic activities prescribed for him because no staff had yet been assigned to work with him. Plaintiffs claim that all persons under 21 who are eligible for BHR services are at risk of psychological and other injuries as a result of the failure of DPW to ensure prompt access to medically necessary services.

The lawsuit cites a variety of deficiencies in DPW's policies that contribute to the delays in service provision including, an unnecessarily time-consuming application process, inappropriate licensing and staff qualification requirements, inadequate payment rates and a failure to track children to determine whether services are being provided. The case covers both DPW's fee-for-service system and its managed care programs. One count of the complaint focuses on DPW's HealthChoices program, claiming that DPW failed to obtain from its Behavioral Health managed care contractors, the federally required proofs and assurances of their ability to provide services as promptly as is appropriate. In the case of Philadelphia, DPW had failed to respond to a request from the city to waive certain licensing requirements so that they could enroll and train several interested home health agencies that employ psychiatric nurses and aides to help fill the BHR staff shortage.

The Court has denied DPW's motion to dismiss the case and has certified the case to proceed as a class action. Plaintiffs are in the midst of discovery (a formal method of obtaining information from the defendant and others) concerning the extent and causes of the delays throughout the state.

Plaintiffs are represented by Rachel Mann of the Disabilities Law Project and by Edmond Tiryak, Esquire. For more information contact Ms. Mann at 215-238-8070.

Class Action Update:
DPW Agrees to Changes in its HealthChoices Pharmacy System

Many Medicaid recipients enrolled in HealthChoices have been having a difficult time getting their prescriptions filled - including prescriptions for psychotropic and other mental health related medications. As a result of a class action lawsuit called Metts v. Houstoun, DPW has agreed to make changes in the way the HealthChoices HMOs in the Southeast respond to the presentation of prescriptions at the pharmacies.

The most significant change concerns ongoing medications - that is, medications that the member has already been taking as part his or her ongoing treatment. HealthChoices HMOs are now required to provide at least a 15 day supply of any ongoing medication at the time the prescription is presented, unless the member has previously received a written notice of termination or reduction, explaining the member's appeal rights and the member has not filed a timely appeal. The notice should have a simple tear-off form that the member can fill out and return in order to file the necessary appeal.

Often, denial notices will state that the HMO needs additional information from the member's physician to support the medical need for the medication. Even if your child's doctor is gathering additional information to send to the HMO, you must file an appeal to make sure there is no disruption in your child's medication. If there is no tear-off with the notice, simply send a letter to one of the addresses set out on the notice (we recommend the DPW address) saying that you want to appeal the denial and giving your Social Security number, the name of the HMO and of the medication denied, and an address and phone number where you can be reached. Send your letter as soon as possible, but in any event make sure it is mailed within 10 days of the date on the denial notice.

Regardless of whether a prescription is new or ongoing, Healthchoices HMOs are required to send written notices explaining the reasons for denials and explaining appeal rights every time a prescription is turned down at the pharmacy. Under the settlement agreement, both DPW and plaintiffs counsel will be reviewing all notices of denials and reductions of medications for six months, and will be engaging in other monitoring activities. Any information you may have concerning violations of the rules described above should be reported to the Disabilities Law Project (Ilene Shane or Rachel Mann) at 215-238-8070.

Parents Involved Network (PIN), a project of
Mental Health Association of SE PA
1211 Chestnut Street, 11th Floor
Philadelphia, PA 19107
215-751-1800 or 800-688-4226
Email: law@pinofpa.org