The decision by respondent, United Healthcare, a managed care organization, to reduce the Personal Care Assistant (PCA) hours awarded to petitioner, C.S., from forty (40) hours per week to twenty-five (25) hours per week was reversed on appeal. C.S. v. United Healthcare, 2015 WL 4410104 (June 4, 2015, N.J. Adm.)

C.S. is eighty-eight (88) years old. She began receiving PCA services in February 2012 after suffering a stroke. She lives in her home with her daughter. At the hearing, C.S. testified that she cannot walk, cook, eat, clean herself, use her arms, get out of the house or transfer without assistance. Her daughter works full-time and can assist C.S. only on the weekends. An expert in nursing presented by C.S. at the hearing confirmed that C.S. was wholly dependent on assistance in performing all activities of daily living.

Respondent presented Ray Gridley, a registered nurse, who completed hundreds of assessments for Medicaid applicants requesting PCA hours.  In performing assessments, Mr. Gridley testified that he utilized a Personal Care Assistant (PCA) Nursing Assessment Tool to rate activities of daily living. Points were assigned in various categories based upon the assessor’s observations of areas in which applicants needed hands-on assistance by a PCA.  Mr. Gridley testified that assessments resulted in raw scores of the number of PCA hours needed by applicants, up to a maximum of 25 hours per applicant. Although the governing Medicaid regulations allowed applicants to receive a maximum of 40 PCA hours, Mr. Gridley testified that only the respondent’s Medical Director could approve additional PCA hours above the maximum of 25 hours allowed under respondent’s policy, and that he was not aware of the criteria used by the Medical Director in approving additional PCA hours.

Based upon the evidence presented at the hearing, the administrative law judge (ALJ) entered an order reversing respondent’s decision, and restoring petitioner to 40 PCA hours per week. The ALJ ruled, first, that United Heathcare failed to meet its burden proving that the reduction in PCA hours was justified. Ray Gridley, the only witness presented by respondent, had not assessed petitioner and was not personally familiar with petitioner’s care needs. He also could not testify as to the criteria used by the Medical Director in evaluating an applicant’s need for PCA hours above the 25 hours, and whether petitioner met the criteria established by the Director.

Second, the ALJ ruled that the assessment tool used by respondent unfairly imposed an artificial cap of 25 PCA Hours although Medicaid regulations allow a maximum of 40 PCA hours to be awarded: “Fundamental fairness … demand[s] that the respondent create a more equitable scoring assessment that neither unfairly holds down, or inflates, a recipient’s ability to fairly reflect the number of PCA hours required given their limitations in life activities.”

The case is annexed here – C.S. v. United Healthcare, 2015 WL 4410104 (June 4, 2015, N.J. Adm.) (ALJ Decision)

The Final Agency Decision is annexed here – C.S. v. United Healthcare (Final Agency Decision)

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