SH: Fighting Cuts in Services

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Tags: Client Stories

This year, we have received a flood of calls from the families of people who benefit from the Innovations Waiver and whose services have been cut. Here’s the story of one of our clients.

SH is a 29-year-old woman who suffered a traumatic brain injury as a child. She was getting 84 hours of services a week, which enabled her to live safely at home and engage in her community.

Then her LME/MCO, Vaya Health, cut her hours to 78 hours per week and informed her family of its intention to cut her hours more in the coming years. Her parents appealed, and the case landed before an Administrative Law Judge.

Nothing about SH’s condition, living situation, or needs had changed. So how did Vaya justify the cuts? It couldn’t. In court, Vaya’s psychologist testified that 78 hours was the maximum number he would approve, regardless of the needs of the individual. He could not cite any standards or clinical guidelines to explain how he came up with the 78-hour cap—the number appeared to be arbitrary.

The Administrative Law Judge ruled in SH’s favor, saying that Vaya had violated her due process rights. Medicaid decisions must be made using clear standards that the average person can understand. An individual who wants to challenge a decision needs to be able to access and understand the standards used to make that decision. Because Vaya did not have such standards, it violated SH’s rights.

This case was part of Disability Rights NC’s long-term goal of requiring all of the state’s LME/MCOs to provide individuals with the services and supports they need to live and participate in their communities. People with disabilities have the right to live as independently as possible in the community of their choice. Making sure they have the services they need is a fundamental part of enforcing that right.