I represented the 84-year old petitioner in P.R.-P. v. United Healthcare , a case in which we successfully appealed the reduction in her Medicaid personal care assistant (“PCA”) hours. The petitioner suffers from advanced Alzheimer’s disease, coronary artery disease, diabetes, congestive heart failure, kidney failure, renal failure, blindness, and bladder incontinence, among other things. She requires the use of an oxygen machine continuously, and she has periods of sleeplessness, with agitation, for up to three days. In 2012, the petitioner had been approved for 40 PCA hours under Medicaid Global Options. In 2015, after United Healthcare began administering her benefits under a Medicaid managed health plan, a reassessment was conducted by United Healthcare field care coordinator Ray Gridley, R.N., using a new PCA Nursing Assessment Tool that had been in operation for less than a month. As a result of that assessment, United Healthcare reduced the petitioner’s PCA hours from 40 to 29.

Ray Gridley’s assessment revealed no improvement in the petitioner’s condition. In fact, at the hearing, the petitioner’s family testified at length that, in the three (3) years that elapsed since the original assessment, her condition has declined and the need for assistance has increased. Her cardiac condition has declined to the point that a cardiac direct monitor was installed; her arthritis has advanced; she has sleep apnea and requires a breathing machine day and night.  She must be carried to the car for medical appointments.

Following an administrative law hearing, Hon. Leland S. McGee, ALJ issued a comprehensive decision. The judge found that, based upon the credible evidence presented, there were “inconsistencies in the number of hours assigned in the assessment tool itself, [and]… incongruities in the time allocated for tasks and the time required to perform those tasks.” He questioned much of the information contained in Mr. Gridley’s PCA Nursing Assessment Tool:

The evidence indicates that petitioner meets the criteria of “severely impaired”; however, she was determined to be “moderately impaired.” … Further, in the assessment tool, under the category “ADLs,” respondent indicated that petitioner requires “extensive/max assist” (weight-bearing support), which allows for up to 45 minutes per day of assistance…. However, petitioner was only allocated 2 minutes per day. There is no explanation for why she was only granted 2 minutes when the lowest designation, “supervision/limited assist,” allows up to 15 minutes per day. Further, respondent acknowledges that, as stated on the assessment tool itself, the times listed for each activity are only guidelines, and more time may be allocated than the specified “limits.”

The judge further noted that the petitioner’s family does her shopping, and no time was allotted for this activity. In addition, the family prepares separate meals for the petitioner, but there was no allotment for that time. As the judge reasoned, “This fails to ‘meet the needs of the family’ pursuant to N.J.A.C. 10:60-1.2.”

 Judge McGee concluded that the respondent had failed to meet its burden of proving that the reduction of PCA hours was proper:

[T]here is no dispute that since the initial assessment in 2012, petitioner’s medical condition has declined. It is neither logical nor equitable to accept that the number of hours needed to provide for her care would decrease regardless of the assessment tool used. In the absence of evidence that the initial assessment allocating 40 hours of PCA was flawed, any subsequent assessment that results in a decreased need for assistance for a person whose health has declined is inherently flawed or improperly administered.

Judge McGee’s Initial Decision was filed April 13, 2016 with the Director of the Division of Medical Assistance and Health Services, who has 45 days to adopt, modify or reject the decision; otherwise, it becomes a final decision.

A copy of P.R.-P. v. United Healthcare can be found here –  P.R.-P. v. United Healthcare