Under federal and state regulations, the State of California must make an eligibility determination within 45 days after a Medicaid application is filed. Unfortunately, California often fails to meet the 45 day deadline. However, a recent ruling by a state court ends the processing delay by compelling California to meet the timeline established by Medicaid regulations. Rivera v. Douglas (Alameda County Superior Court Case No. RG14740911, January 20, 2015)

In the Fall of 2014, four applicants who had not received a timely determination of their eligibility for Medicaid benefits and a coalition of legal services organizations filed suit in Alameda County Superior Court against the California Department of Health Care Services, the state agency responsible for administering the Medicaid program (called Medi-Cal in California), and its Director. Plaintiffs claimed that the Department failed to grant or deny Medicaid benefits within 45 days of receiving their applications as legally mandated by applicable regulations. To cure the alleged violation, plaintiffs sought a preliminary injunction granting the following relief: (1) granting provisional benefits in all cases involving Medicaid applications pending more than 45 days where eligibility appears likely, and (2) sending written notices to all other applicants of their right to a hearing to secure a prompt ruling on their pending applications.  

At the hearing, defendants admitted that the State failed to issue eligibility determinations within 45 days after defendants’ Medicaid applications were filed. The Department also admitted that there was a backlog of thousands of Medicaid applications for which no timely eligibility determination had been made. Further, the Court denied defendants’ claim that the delays were caused by “administrative or other emergency beyond the agency’s control,” holding that the problems identified as causing the delays were not beyond the Department’s ability to control. Also, while recognizing that the federal Center for Medicare and Medicaid Services had primary jurisdiction of the matter, the Court ruled that it was not precluded from acting where, as here, the Department admitted that it was not copying with its duty under the law. As a result, the Court ruled that the Department failed to comply with its duty under federal and state regulations to grant or deny Medicaid eligibility within 45 days of the date the application was filed.

The Court granted plaintiffs’ request for a preliminary injunction. As to relief, the Court entered an Order prohibiting the Department from “failing to comply with its duty to make [Medicaid] eligibility determinations within 45 days.” Alternatively, the Court gave the Department discretion to grant provisional benefits in all cases involving Medicaid applications pending more than 45 days where eligibility appeared likely. The Court also ordered the Department to send written notices to all other applicants of their right to a hearing to secure a prompt ruling on their pending applications.  

The Court Order is annexed here –  Order Granting Motion for Preliminary Injunction

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