Mendez v Mackereth Complaint

8/10/2019 Mendez v Mackereth Complaint

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IN THE UNITED STATES DISTRICT COURTFOR THE EASTERN DISTRICT OF PENNSYLVANIA

MELISSA MENDEZ andAMINATA DIAOon behalf of themselves and all otherssimilarly situated,

:::

CIVIL ACTION

: NO. 2014-Plaintiffs :

: COMPLAINT

v. :: CLASS ACTION

BEVERLY D. MACKERETH,Secretary of the PennsylvaniaDepartment of Human Services,

and

DIONISIO MIGNACCA,Executive Director of the PhiladelphiaCounty Assistance Office,

Defendants.

:::::::::::

COMPLAINT

PRELIMINARY STATEMENT

1. This action challenges the Pennsylvania Department of Human Services (DHS

formerly the Department of Public Welfares, or DPWs) processes for implementing sev

in Medicaid benefits for adults in Pennsylvania. More than 1.1 million low-income and

vulnerable individuals have been assigned to one of three Medicaid benefits packages w

limitations on services, on or after January 1, 2015, through the use of three algorithms w

secret standards. DHS has sent two rounds of inadequate notices that first did not expla


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medical needs, resulting in potentially serious but avoidable medical problems, as well a

needless confusion.

2. DHS administers Pennsylvanias Medicaid program as well as a state funded Me

lookalike program known as Medical Assistance, most of whose recipients will be transi

federally funded Medicaid starting January 1, 2015. As part of its Healthy Pennsylv

initiative, DHS is electing to limit Medicaid benefits for adult Medicaid recipients beginn

January 1, 2015, with severe limitations for some. While federal law confers upon state

latitude in designing Medicaid benefits packages, states must comply with due process

requirements of the United States Constitution, as well as the detailed federal statutory a

regulatory Medicaid scheme. The Social Security Act and its implementing regulations

that states administer Medicaid in a manner consistent with simplicity of administration

best interests of the recipients, using reasonable standards.

3. This class action seeks declaratory, injunctive, and notice relief on behalf of adul

Medicaid and state funded Medical Assistance recipients who will be eligible for federal

funded Medicaid on or after January 1, 2015 and whom DHS has determined are not me

frail and therefore assigned to lesser Medicaid benefits packages via unascertainable stan

with inadequate notice. DHSs actions violate the Social Security Act and the Due Proc

Clause of the Fourteenth Amendment to the United States Constitution.

4. The Plaintiffs seek to enjoin DHS from assigning Medicaid and state funded Me

Assistance recipients to severely reduced benefits packages without using ascertainable


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JURISDICTION

5. This Courts subject matter jurisdiction over this action is conferred by 28 U.S.C

and by 28 U.S.C. 1343(a)(3) and (4), which provide for jurisdiction over actions unde

United States Constitution and civil rights laws.

6. Plaintiffs claims for declaratory, injunctive, and other relief are authorized by 28

2201 and 2202, Rule 57 of the Federal Rules of Civil Procedure, and by 42 U.S.C.

7. Plaintiffs claims for attorneys fees and costs are authorized by 42 U.S.C. 198

8. Venue is proper in the Eastern District of Pennsylvania pursuant to 28 U.S.C. 1

PARTIES

9. Plaintiff Melissa Mendez is a citizen of the United States of America and a resid

Philadelphia County, Pennsylvania.

10. Ms. Mendez is a 33-year-old recipient of state funded Medical Assistance benef

will receive Medicaid coverage on January 1, 2105. She has been improperly assigned t

Healthy PA PCO Medicaid benefits package as a result of the Defendants unascertaina

standards and flawed procedures. She was sent inadequate notice of the cuts to her Med

benefits by the Defendants.

11. Plaintiff Aminata Diao is a citizen of Mali and a resident of Philadelphia County

Pennsylvania. She came to the United States in 2001 and was granted withholding of r

status because she would be persecuted if she returned to her home country. She is lawf

h d h d k d l bl f bl b f


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standards and flawed procedures. She was sent inadequate notice of the cuts to her Med

benefits by the Defendants.

13. Defendant Beverly D. Mackereth is the Secretary of the Pennsylvania Departme

Public Welfare (DHS). She is responsible for ensuring that DHSs Medicaid program is

and efficiently administered according to reasonable standards, and that the Pennsylvani

Medicaid program complies with the Social Security Act, its implementing regulations, a

United States Constitution. She is sued in her official capacity.

14. Defendant Dionisio Mignacca is the Executive Director of the Philadelphia Coun

Assistance Office. He is responsible for ensuring that the Philadelphia County Assistanc

properly and efficiently administers the Medicaid program according to reasonable stand

compliance with the Social Security Act, its implementing regulations, and the United S

Constitution. He is sued in his official capacity.

CLASS ACTION ALLEGATIONS

15. Plaintiffs Melissa Mendez and Aminata Diao bring this action on behalf of them

and all others similarly situated, pursuant to Rules 23(a), (b)(2), and (c)(5) of the Federal

of Civil Procedure.

16. The Plaintiff class consists of all current adult Medicaid and state funded Genera

Assistance-related Medical Assistance (GA-MA) recipients who will be eligible for fede

funded Medicaid on or after January 1, 2015 and whom DHS has not found to be medica

l h l h l h d d b f


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medically frail, resulting in their placement in the Healthy Medicaid benefits package on

January 1, 2015.

18. The second subclass consists of all current adult state funded General Assistance

Medical Assistance (GA-MA) recipients who will be eligible for federally funded Medic

or after January 1, 2015 and whom DHS has not found to be medically frail, resulting in

placement in the Healthy PA PCO Medicaid benefits package on or after January 1, 20

19. The requirements of Rules 23(a) and (b)(2) are met in that:

a. The class and the subclasses are so numerous that joinder of all members is

impracticable. A total of 197,566 current Medicaid and state funded GA-MA recipients

been assigned to either the Healthy or Healthy PA PCO Medicaid benefits packages o

January 1, 2015, comprising the class. 149,606 current Medicaid recipients have been a

to the Healthy Medicaid benefits package on or after January 1, 2015, constituting the f

subclass. 47,690 current GA-MA recipients have been assigned to the Healthy PA P

Medicaid benefits package effective January 1, 2015, constituting the second subclass.

b. There are questions of law and fact common to the class and both subclasses,

whether the Defendants practices violate the United States Constitution, and to the first

subclass, including whether the Defendants practices violate the Social Security Act. T

Defendants have used unascertainable standards and sent inadequate notice to all membe

class and subclasses;

c. The claims of the representative parties are typical of the claims of the class m


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by competent counsel who have represented classes and subclasses in numerous other ca

involving Medicaid and other public benefits programs; and

d. The Defendants have acted on grounds generally applicable to the members o

class and the subclasses, thereby making appropriate final injunctive and declaratory reli

respect to the class as a whole and with respect to each subclass as a whole.

LEGAL FRAMEWORK

20. Medicaid is a joint federal-state assistance program authorized by Title XIX of th

Security Act that provides health insurance coverage to certain low-income individuals.

Medicaid is administered by the states under the supervision of the United States Depart

Health and Human Services (HHS). 42 U.S.C. 1396a-1369w-5. DHS administers th

Medicaid program for Pennsylvania.

21. The Social Security Act requires states to administer their Medicaid programs ac

to reasonable standards. 42 U.S.C. 1396a(a)(17).

22. The Social Security Act further requires states to operate their Medicaid program

manner consistent with simplicity of administration and the best interests of the recipien

U.S.C. 1396a(a)(19).

23. Medicaid recipients with serious health problems that render them medically frai

assigned to Medicaid benefits packages that meet their health care needs. 42 U.S.C. 1

7(a)(2)(B)(vi); 42 C.F.R. 440.315(f).

d h l f h h d h d


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25. Also under the Due Process Clause of the Fourteenth Amendment, individuals h

right to meaningful, individualized notice, supported by legal authority, and an opportun

heard before their Medicaid benefits are terminated or otherwise altered adversely.

26. The Social Security Act provides that any person who is denied assistance under

her state Medicaid program is entitled to an opportunity for a fair hearing. 42 U.S.C.

1396a(a)(3).

27. Under the federal regulations that interpret and apply the Social Security Act and

Process Clause of the Fourteenth Amendment, individuals have the right to advance noti

fully explain the factual and legal bases for termination, suspension, or reduction of Med

eligibility or covered services. 42 C.F.R. 431.206-211, 431.230, & 435.919.

STATEMENT OF FACTS

Healthy Pennsylvania s Medicaid Benefits Cuts

28. In September 2013, Pennsylvania Governor Tom Corbett announced an overhau

Pennsylvanias Medicaid system, called Healthy Pennsylvania . Healthy Pennsylva

includes new limitations on benefits for more than 1.1 million adult Medicaid and state f

Medical Assistance recipients, effective January 1, 2015, with some recipients facing sev

benefits cuts. Also effective January 1, 2015, it features expansion of Medicaid for indiv

between the ages of 19 and 64 with incomes at or below 133% of the federal poverty gui

(plus a 5% income disregard), as authorized by the Patient Protection and Affordable Ca


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33. The Healthy benefits package is significantly less generous than both the Healthy

benefits package and current Medicaid benefits packages. Among other cuts, it includes

strict annual limits of four specialist doctor visits, six radiology tests, and $350 in labora

services. If they are not found to be medically frail, parents (and other adult relatives wh

caring for children) with very low incomes, young adults who have aged out of foster ca

individuals awaiting enrollment in the Healthy PA PCO plan will be assigned to the H

benefits package.

34. Named for Pennsylvanias planned Medicaid expansion managed care network,

Healthy PA PCO benefits package is less generous than the Healthy Plus benefits packa

with different cuts in services than the cuts in the Healthy package. Most significantl

the Healthy PA PCO package will not provide non-emergency medical transportation fo

individuals who are too sick and/or too poor to be able to transport themselves to their m

appointments. It also will provide no dental coverage, reduced optometry services, and

behavioral health managed care systems that are expected to have more limited provider

networks than traditional Medicaid. Current GA-MA recipients and individuals who are

eligible for Medicaid through expansion will be enrolled in the Healthy PA PCO ben

package unless they are medically frail.

35. Federal Medicaid regulations require state Medicaid agencies to seek and obtain

of benefits packages from HHS prior to implementation. 42 C.F.R. 430.10-20, 440.3

On December 17, 2014, HHS approved the Healthy Plus and Healthy PA PCO benef


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packages, or near equivalents, until HHS approves the Healthy package. Accordingly,

individuals assigned to the Healthy benefits package may not be subject to severe benefi

until sometime after January 1, 2015. Other Medicaid recipients and GA-MA recipients

receive the Healthy Plus and Healthy PA PCO benefits packages as planned on Januar

36. Federal Medicaid regulations require state Medicaid agencies to develop definiti

medical frailty that encompass, at the very least, individuals with disabling mental diso

individuals with serious and complex medical conditions, and individuals with physical

mental disabilities that significantly impair their ability to perform one or more activities

living. 42 C.F.R. 440.315(f). DHS also deems individuals with chronic substance ab

disorders as medically frail through a definition that it proposed as part of Healthy Pe

implementation, but has not promulgated as a regulation or published as subregulatory g

37. DHSs definition of medical frailty includes some additional details, but not man

example, it notes that an individual is medically frail if he or she has a permanent disab

significantly impairs their function, and provides a few examples of qualifying disabilit

does not explain what the standard for demonstrating a significant impairment is.

38. Instead of elaborating on its definition of medical frailty to establish ascertainab

standards, in October 2014, DHS revealed on its Healthy Pennsylvania implementati

and through internal guidance that it would use complex and opaque internal systems, fe

three secret algorithms, to determine which Medicaid applicants and recipients would be

medically frail, and therefore eligible for the best Healthy Plus benefits package.


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determination process can or will analyze Medicaid claims data to determine which adul

Medicaid recipients are medically frail. It intends to use its claims determination proces

analyze claims data for Medicaid recipients when they complete mandatory annual

reapplications, and on a quarterly basis for Medicaid recipients assigned to the Healthy p

not those assigned to the Healthy PA PCO plan). It also may use the claims determina

process to evaluate claims data for new Medicaid applicants who are known to DHS bec

they received Medicaid in the past.

40. Beginning on November 5, 2014, DHS began sending pre-transition letters to

and GA-MA recipients who were found medically frail by the claims determination proc

informing them that they would be enrolled in Healthy Plus. The same letters went to re

who qualify for Healthy Plus automatically by virtue of their Medicaid categorical eligib

because they are seniors or pregnant women, or have long term disabilities. A copy of t

is attached as Exhibit A.

41. Also beginning November 5, 2014, DHS began sending similar pre-transition le

Medicaid and GA-MA recipients who were not found medically frail by the claims

determination process, informing them that they will be enrolled in the Healthy or H

PCO plans. Recipients of this second batch of letters were instructed that, if they believ

their assigned benefits package would not meet their medical needs, they could complete

screening questionnaire, either online or by telephone, no later than November 26, 2014

of the Healthy letter is attached as Exhibit B, and a copy of the Healthy PA PCO


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2015. To the contrary, they stated that, This initiative will ensure that Pennsylvanians h

increased access to quality affordable healthcare. As of January 1, 2015, coverage that y

members of your household are receiving may change.

43. The pre-transition letters referred to both the Healthy and the Healthy Plus plans

comprehensive, with no details about how the plans differ or how Healthy is more lim

44. The pre-transition letters did not inform individuals tentatively assigned to Healt

Healthy PA PCO plan that, if they failed to complete a health screening questionnaire, th

would not get Healthy Plus.

45. The pre-transition letters did not confer appeal rights.

46. The pre-transition letters were at a level of complexity that required at least a yea

half of college education to comprehend.

47. As a result of the misleading and deceptive statements in the pre-transition letter

individuals tentatively assigned to the Healthy or Healthy PA PCO benefits packages

unable to determine whether these benefit packages would meet their needs, and therefor

whether they should complete the health screening questionnaire.

48. The pre-transition letters advised recipients assigned to Healthy and Healthy Plu

they could call various telephone numbers for information about the benefits packages.

Recipients and individuals attempting to assist them who called those numbers had great

difficulty in reaching DHS customer service representatives. Recipients and individuals

attempting to assist them who succeeded in reaching customer services representatives h


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2014. As a result, many individuals had a very short time frame for completing the heal

screening questionnaire.

50. The pre-transition letters advised recipients that they could complete the health s

questionnaire only via DHSs online application portal or via a dedicated telephone call c

Some Medicaid and GA-MA recipients who tried to complete the questionnaire online o

the phone experienced difficulties with the online portal and/or the call center.

51. As a result of the misleading and deceptive pre-transition letters, the short time f

completing the screening questionnaire, and recipients difficulties in understanding the

and accessing the questionnaire, only 2,658 Medicaid and GA-MA recipients completed

questionnaire by the November 26, 2014 deadline.

52. Recipients who could access the health screening questionnaire found that it ask

of closed-ended questions about recent medical situations and diagnoses. A copy is atta

Exhibit D. There is no opportunity to explain individual circumstances that may make a

individual medically frail, such as unusual but debilitating medical conditions. The ques

ask for responses that may cause shame or be stigmatizing, such as whether a recipient h

HIV/AIDS, whether a recipient has been treated for use of street drugs, and whether a re

friend is concerned about his or her alcohol use.

53. Medicaid recipients who were first approved for Medicaid in November 2014 w

sent pre-transition letters or given the opportunity to complete health screening questionn

because they were not receiving Medicaid at the time that the transition letters were gene


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54. Similarly, individuals whose Medicaid is scheduled to close before January 1, 20

who have a right to appeal the closure and receive benefits while their appeals are pendin

not been provided with a mechanism either to complete the health screening questionnai

have their current benefits packages continue pending resolution of their appeals.

55. Medicaid and GA-MA recipients who successfully completed the health screenin

questionnaire were not guaranteed the Healthy Plus benefits package. Instead, DHS ran

to the questionnaire through a second secret algorithm separate from the secret algorith

underlying the claims determination process to determine whether the recipient is

presumptively medically frail. The second secret algorithm will also be used to evaluate

frailty for new Medicaid applicants. DHS has refused to inform recipients of the second

algorithm.

56. Medicaid and GA-MA recipients whom the second secret algorithm determined

medically frail, or who did not complete the screening questionnaire, were assigned to th

Healthy or Healthy PA PCO benefits packages effective January 1, 2015.

57. Medicaid and GA-MA recipients found presumptively medically frail based on t

questionnaire and second secret algorithm will not be given the Healthy Plus package on

term basis automatically. Instead, they will be enrolled in Healthy Plus while their cases

referred for clinical validation via a third secret algorithm.

58. DHS sent out transition notices with these plan assignments beginning on Dec

2014. Copies are attached as Exhibit E.


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60. The transition notices provided ten days from the dates printed on the notices for

recipients to appeal and receive Healthy Plus benefits pending fair hearings, as required federal law. See 42 C.F.R. 431.211, 431.230. However, some notices were postmar

the dates printed on the notices, providing recipients with less than ten days to appeal.

61. The Healthy and Healthy PA PCO transition notices did not outline the specific

why individual recipients do not qualify for Healthy Plus.

62. DHSs clinical validation process for those found presumptively medically fra

on the health screening questionnaire consists of telephone calls from DHSs clinical sta

Medicaid and GA-MA recipients medical providers. DHS has said that the clinical vali

team will ask about diagnoses, prognoses, and treatment plans, but it has refused to infor

recipients of the teams call script or standards for determining medical frailty. Thus DH

created a third unascertainable standard in its clinical validation process.

63. Medicaid and GA-MA recipients who meet the clinical validation teams secret s

will remain in Healthy Plus. Medicaid and GA-MA recipients who do not meet the secr

standards will be moved from the Healthy Plus package to which they have been tentativ

assigned to the less generous Healthy and Healthy PA PCO packages. DHS has not d

an appeals process for recipients who are moved out of Healthy Plus following clinical

validation.

64. DHS has stated that pregnant women will be assigned to the Healthy Plus packa

While women who are pregnant at the time of application are easily identifiable, as the M


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to Healthy Plus, nor did they tell recipients how to notify DHS of a pregnancy for this pu

As a result, women who are pregnant may be wrongly placed in, or remain in, the Health Healthy PA PCO categories.

Plaintiffs

65. On October 27, 2014, Plaintiff Melissa Mendez tripped and fell, fracturing her ja

breaking three teeth, and chipping a fourth tooth.

66. On October 28, 2014, Ms. Mendez went to the Temple University Dental School

treatment. Dentists at the Dental School immediately sent her to the Temple University

emergency room, and called in additional doctors from Episcopal Hospital to help there.

of ten to twelve doctors from two hospitals worked together to treat her injuries, includin

her jaw shut.

67. On October 30, 2014, Ms. Mendez had surgery. She was discharged from Temp

University Hospital on October 31, 2014.

68. A social worker at Temple University Hospital filed a Medicaid application for M

Mendez during her hospital stay. The application is still pending. On November 6, 201

Mendez filed a second Medicaid application on her own behalf.

69. Ms. Mendez was never given an opportunity to complete the health screening

questionnaire as part of these applications.

70. In early December 2014, Ms. Mendez was approved for GA-MA as a result of h

November 6 2014 application Just a few days later she received a notice dated Decem


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71. Ms. Mendez requires dental coverage to fix her three broken teeth and one chipp

The Healthy PA PCO benefits package is insufficient to meet those medical needs.72. Plaintiff Aminata Diao is a mother of two with a history of physical and mental h

problems. Earlier this year, she suffered a bad fall and injured her back badly, rendering

unable to work. She also suffers from asthma.

73. A few years ago, while struggling with homelessness, a history of domestic viole

severe sleep deprivation, she suffered a psychotic break in New York City while travelin

from a visit with friends. She believed that people were communicating with her throug

computers and that she was speaking back to them telepathically. She was hospitalized

several months at Bellevue Hospital in New York. She still suffers from depression.

74. Ms. Diao received a pre-transition letter in November 2014. She understood tha

would be moved to the Healthy benefits package on January 1, 2015, but did not underst

she would face severe benefits cuts. She also did not understand that she should comple

health screening questionnaire to receive a better benefits package.

75. On December 10, 2014 or December 11, 2014, Ms. Diao received a transition no

confirming that she would be assigned to the Healthy benefits package. The transition n

was dated December 5, 2014 but postmarked December 9, 2014. The notice stated that

must appeal by December 15, 2014, within six days of the mailing, to continue receiving

current benefits package pending a fair hearing.

76. Because of her longstanding physical and mental health diagnoses, Ms. Diao app


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CAUSES OF ACTION

Violations of the Due Process Clause of the Fourteenth Amendment All Recipients

77. Defendants have assigned Medicaid and GA-MA recipients to the Healthy and

PA PCO benefits packages, with their markedly restricted benefits limits, using standard

not disclosed to recipients and applying three secret algorithms to determine their eligibi

78. Defendants have failed to provide proper, individualized notice of Medicaid reci

and GA-MA recipients assignment into the Healthy and Healthy PA benefits packag

includes the specific reasons for their assignment and is supported by valid legal authori

79. Defendants actions violate the Due Process Clause of the Fourteenth Amendme

are actionable pursuant to 42 U.S.C. 1983.

Violation of the Social Security Act First Subclass Only

80. Defendants have failed to provide proper, individualized notice of Medicaid reci

assignment into the Healthy benefits package that includes the specific reasons for their

assignment, provides notice and an opportunity to appeal and receive benefits pending fa

hearings ten days in advance, and is supported by valid legal authority.

81. Defendants actions violate the Social Security Act, 42 U.S.C. 1396a(a)(3), an

actionable pursuant to 42 U.S.C. 1983.

PRAYER FOR RELIEF

WHEREFORE, Plaintiffs respectfully request that this Court:


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unconstitutional under 42 U.S.C. 1396a(a)(3), the Due Process Clause of the Fourteent

Amendment to the United States Constitution, and 42 U.S.C. 1983;(3) Enter preliminary and permanent injunctive relief, requiring the Defenda

(a) Cease use of its three secret algorithms and health screening que

immediately;

(b) Cease moving existing Medicaid and GA-MA recipients from th

existing benefits packages based on unascertainable standards and inadequate notice, or,

alternative, provide current Medicaid and GA-MA recipients with the planned Healthy P

benefits package, until such time as proper ascertainable standards and adequate and

individualized notice are in place; and

(4) Award Plaintiffs their costs and reasonable attorneys fees; and

(5) Provide such other and further relief as this Court deems just and proper

Respectfully submitted,

/s/ Louise HayesLouise Hayes (ID No. 78581)Electronic Signature # LEH8872Amy E. Hirsch (ID No. 42724)Community Legal Services1410 West Erie AvenuePhiladelphia, PA 19140(215) 227-2400

Kristen M. Dama (ID No. 207079)Community Legal Services1424 Chestnut Street


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Carrboro, NC 27510(919) 968-6308

Attorneys for the Plaintiffs

Dated: December 22, 2014


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Complaint Exhibit B 1 of 4


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Health Care Needs Questionnaire


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Please answer the following questions to the best of your knowledge. It is not required that youcomplete this form. However, it is to your benefit to answer these questions because it will helpidentify what health care package best meets your individual needs. If you are uncomfortableanswering any portion of this questionnaire, then ignore the question and move to the next

question. All information you provide will remain confidential.

1. In general, compared to other people your age, how would you rate your health?(select only one)

a. Excellentb. Very goodc. Goodd. Faire. Poor

2. In general, compared to other people your age, how would you rate your mental health?(select only one)

a. Excellentb. Very goodc. Goodd. Faire. Poor

3. Are you currently receiving services on a daily basis from family, friends, or an agency/paprovider for each of the following activities? (answer each question)

YES NOPersonal hygiene/grooming --such as brushing teeth, washing face, combAssistance walking or if you use a wheelchair, help once seated in chairHelp transferring from one place to another --such as moving from chchair to toilet or bed to standing positionHelp eating -- Using a feeding tube or someone needing to feed you with aspoonManaging medications --includes help with reminders to take medicines, bottles, taking the correct dosage, giving injections

This document is for example purposes only.

4. In the last twelve months, how many times did you stay one or more nights in a hospital?(d h i li d f hildbi h)


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(do not count hospitalized for childbirth)

a. Not been hospitalized in the last twelve monthsb. One timec. Two times

d. Three or more times

5. If hospitalized in the last twelve months, were any of these hospital stays related to mentalhealth issues?

a. Not hospitalized in last twelve monthsb. None for mental health problemc. One time for mental health problem

d. Two times for mental health probleme. Three or more times for mental health problem

6. In the last twelve months, how many times have you used an emergency room?

a. Not used emergency room in the last twelve monthsb. One to two timesc. Three to five timesd. Greater than five times

7. In the last twelve months, how many times have you been seen in an office or clinic by amedical professional for a physical health or a mental health concern? Bubble: (A medical professional could be a doctor, nurse practition er, physician amental health professional.)

a. No visits in last twelve months

b. One to four timesc. Five to nine timesd. Ten or more times

This document is for example purposes only

8. Has a doctor, nurse or medical professional ever diagnosed or treated you for concerns ofany of the following:


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any of the following:

a. Never diagnosedb. Alcoholc. Street Drugs

d. Prescription Medication Use

9. Are you concerned about your use of alcohol or drugs? Y/NBubble: (If you are uncomfortable answering any portion of this questionnaire, then ignore question and move to the next question.)

10. Is a friend, relative or anyone else concerned about your use of alcohol or drugs?

Bubble: (If you are uncomfortable answering any portion of this questionnaire, then ignorequestion and move to the next question.)

11. How many medications is your doctor currently directing you to take?Count each bottle of medication only once, even if you take it often.Include inhalers and liquids. Do not count over-the-counter (non-prescription) medications?

a. Not taking any medications at this time.

b. Currently taking one to three medications.c. Currently taking four to eight medications.d. Currently taking more than eight medications.

12. My height is: _________ feet and ___ inches

My weight is: _________ pounds

13. Has a doctor, nurse, or other medical professional EVER told you that you had any of thefollowing? For each select Yes No or youre Not sure


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following? For each, select Yes, No, or you re Not sure.bubble: (A medical professional could be a doctor, nurse practitioner, physician assistant omental health professional.)bubble: (Do not be concerned if you have not heard of a condition on this l ist. JusKnow/Not Sure)

YES NO Dont Know/ Not Sure

CancerALS or muscular dystrophyAsthmaAutismBipolar disorderBleeding disease (hemophilia)Cystic fibrosisDepressionDiabetesEmphysema/COPDHeart attackHeart failure or Heart transplantHIV or AIDS or Other immune deficiency

Intellectual disability (previously called mental retardation)Kidney failure, transplant or dialysisLeukemiaLiver failure/cirrhosis or Liver transplantLung (pulmonary) hypertensionLung transplantMultiple sclerosisObsessive Compulsive Disorder

Pancreas and/or small bowel transplantPanic DisorderPeritonitisPost Traumatic Stress DisorderPsychotic disorderQuadriplegia or paraplegiaSchizophrenia or Schizoaffective DisorderSevere joint or back pain or LupusSickle cell diseaseSkin ulcers/woundsStrokeSubstance use disorderTracheostomy or ventilator


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N

Your Medical Assistance Benefits


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Your Medical Assistance Benefits

Which package?When?Who?

Starting Jan 01, 2015 Healthy Plus

:(Starting Jan 01, 2015) You continue to be eligible for health care coverage, however theremay be some new service limitations.

This is the law we used to make this decision:42 CFR 435.603, 55 Pa. Code 141.71, 62 P.S.

201(2), 403(b), Healthy PA 1115 waiver.

You will receive the Healthy Plus benefit package, effective 01/01/2015, based on your permanentdisability, pregnancy or need for long-term care or waiver services. For a list of services offered in thisbenefit package and their limits, refer to the enclosed benefit comparison chart insert.

If you would rather receive the Healthy benefit package instead of the Healthy Plus benefit packagebecause you think you do not need extensive medical services, contact the Statewide Customer Service

Center at 1-877-395-8930, or 1-215-560-7226 (if you live in Philadelphia) by 12/13/2014.

Who no longer qualifies?

When?Who?Starting Jan 01, 2015

are currently enrolled in has been discontinued. You will continue to receive your benefits untilDecember 31, 2014. Based on the information in your records, you qualify for Healthy PA PrivateCoverage Option. See later in this notice for more details.

This is the law we used to make this decision:42 CFR 435.603, 55 Pa. Code 141.71, 62 P.S. 201(2), 403(b), Healthy PA 1115 waiver.

Eligibility for Medical Assistance transportation ends on the day your medical assistance eligibility ends.

This is the law we used to make this decision: 55 Pa. Code 2070.41(c), 62 P.S. 201(2), 403(b),Healthy PA 1115 waiver.

Who qualifies?

:(Starting Jan 01, 2015) Effective December 31, 2014, the Medical Assistance program that you

N

Your Healthy PA Private Coverage Option Benefits


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Who qualifies?

Who? When? Which package?

Starting Jan 01, 2015 Healthy PA Private CoveragOption

Each family member eligible for Healthy PA Private Coverage Option must choose a Health Plan. If youdo not choose a plan, you will be assigned to one. To enroll or get more information, call1-844-465-8137.

:(Starting Jan 01, 2015) You continue to be eligible for health care coverage, however theservices that you may receive have changed.

This is the law we used to make this decision:42 CFR 435.603, 55 Pa. Code 141.71, 62 P.S. 201(2), 403(b), Healthy PA 1115 waiver.

You will receive the Healthy PA Private Coverage Option plan, effective 01/01/2015, based on theinformation we have in your record. Your record may include medical assistance claims data reviews,your health screening results, your medical assistance category and other case information. Theinformation we have indicates that you are a 21 to 64 year old adult; or a 21 to 64 year old

parent/caretaker of a child under 19 with income over 33 percent of the Federal Poverty Level. Theinformation also indicates that you are not permanently disabled, pregnant or suffering from a conditionsuch as a disabling mental disorder; an active chronic substance abuse disorder; a serious and complexmedical condition; or a physical, intellectual or developmental disability that significantly impairs yourfunctioning. For a list of services offered in this benefit package and their limits, refer to the enclosedbenefit comparison chart insert.

If you have any change in a medical condition and you believe the Healthy PA Private Coverage Op

benefit plan will not meet your needs contact the Statewide Customer Service Center at1-877-395-8930, or 1-215-560-7226 (if you live in Philadelphia) at any time or contact your local County Assistance Office.

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Most phone companies in Pennsylvania provide Lifelineservice. These programs lower your phone costs for one

phone line. Verizon and Verizon North customers can get

Lifeline or Lifeline 135. All other customers get Lifeline 135.

Do you need helpwith your phone b

If you get any of these:

Supplemental Nutrition Assistance Program,

Cash Assistance;Medical Assistance, MA;

National School Free Lunch Program;

Federal Public Housing Assistance;

Supplemental Security Income, SSI; or,

Low Income Home Energy Assistance Progr

you may also be able to getLifeline or Lifeline 135.

Start saving today!See the other side of this flier for a Lifeline form.

Healthy Pennsylvania Private Coverage O


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If you have any questions about this notice...

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You should take time to review this no tice for accuracy.

The judge will call you, your witnesses, anyone helping you, and the CAO.

The judge will call you there in the office, and call anyone helping you.

A face-to-face hear ing with you and the people you bring in the hearing room with a judge and

A telephone hearing at the CAO. You will go to the CAO for your hearing.

A telephone hearing at a place you choose. Tell us which phone number to use, such as your own, or a friend or relatives phone number. If you choose this kind of hearing, make sure wecan reach you at this phone number.

Your Right to Appeal and to a Fair Hearing

If you do not agree with th is decision...

2. Choose the kind of fair hearing you want:

What do es right to appeal mean?Your right to appeal means that you have the right to ask us to review our decision, if you think that we mademistake. You can ask a judge to review the county assistance office's (CAO) decision at a fair hearing.

Do you need legal help?

How can you ask for a fair hearing? Call the CAO to ask for a fair hearing, and Mail the completed, attached Fair Hearing Form to the CAO or Take the completed, attached Fair Hearing Form to the CAO.

Note: You do not have to complete the Fair Hearing Form if the decision is for SNAP (Food Stamps), butfor us to track your appeal if you do.

If you want to f ile an appeal and ask fo r a Fair Hearing...

What is a fair hearing? A fair hearing is a formal meeting where you, the CAO and a judge can talk about your appeal. The judge wilthe law and the department's policies in making a decision. You should be prepared for the meeting. If you wapresent any evidence that supports your claim that the decision was not correct, bring that evidence with you.

1. If you want to appeal our dec is ion, f il l out and s ign the Fai r Hear ing form inc luded in thispacket.

In Philadelphia, call 1-215-560-7226.The call is free. Call Monday through Friday between 8 a.m. and 5 p.m.

If you have questions about this notice or your benefits, you can call the Statewide Customer Service Cen1-877-395-8930.

You can ask for free legal help by visiting Legal Services at


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Fair Hearing Form


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1. Name:

Phone number: Address:

Case Number:

2. Tell us whic h pro gram you w ant to appeal:Medical AssistanceHealthy PA Private Coverage Option

By telephone, at the CAO.

If someone will be helping you with your appeal please fill out the information for the

7. Tell us wh y you disagree with this decision :

___________________________________________________________________________

6. If you will need help at the appeal because of a hearing impairment or other disabilit y,please tell us h ow we can help you. There is no c ost to y ou for this service.

___________________________________________________________________________

___________________________________________________________________________ ___________________________________________________________________________

4. Choose the way you want your hearing:

By telephone, at the phone number you write on this form.

___________________________________________________________________________

Face-to-face, with you and the people you bring in the hearing room with a judgeand CAO staff on the phone.

Face-to-face, with you and the people you bring in the hearing room with a judgeand CAO staff in the hearing room.

___________________________________________________________________________

8. Signature: __________________________________________

9. Date: _______________________________________________

Yes3. Do you want your SNAP benefits to continu e at the same amount p ending th e hearing

decision?

Reminder: You must travel to the assigned Bureau of Hearings and Appeals office for a face-to-facehearing. The location will be assigned to you based on where you live.

No

5. Do you need a free interp reter? Yes No

If yes, what language? ______________________________________________________

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Be sure to carry your ACCESS card with you at all times. When you go to get health care services,please show all of your insurance cards, including your ACCESS card.

Here are some helpful t ips on using Medical Assis tance (those el ig ib le for the Heal thHealthy Plus Benefit Plan):

If you need a new ACCESS card, call: 1-877-395-8930. If you live in Philadelphia, call: 1-215-5607226.

Here are some helpful t ips on using Private Option Coverage (PCO):

Welcome

There is a limit to the number of visits and services you can get. Please talk with your provider or c1-800-537-8862, Option #2, #3, #2 about these limits. If you need services that exceed the limit, yoor your doctor may request a benefit limit exception.

For more information about what is included in these services, call: 1-800-537-8862, Option #2, #3#2.

If you are enrolled in a HealthChoices Managed Care Organization please check with the plan sincthey may provide additional services above those required by the Medical Assistance program.

Please note that if your household income is above 100% of the Federal Poverty Limit, your MAprovider may refuse service if you fail to pay any copayments, but only as long as refusing service to failure to pay copayments is standard practice for that MA provider.

If you are subject to cost sharing, you can reduce your cost sharing, starting January 1, 2016, bycompleting Healthy Behaviors throughout calendar year 2015. Healthy Behaviors include the payincost sharing at the point of service (doctor office, hospital, etc.) and completing an annual wellnessexam at your primary care physician before October 31, 2015. The Department of Public Welfare wautomatically track completion of these Healthy Behaviors.

Be sure to carry your PCO card with you at all times. When you go to get health careservices, please show all of your insurance cards, including your PCO card.

If you need a new PCO card, please contact your PCO.

There is a limit to the number of visits and services you can get. Please talk with yourPCO about these limits. For more information about what is included in these services,call your PCO.

Please note that if your household income is above 100% of the Federal Poverty Limit,your Private Coverage Option provider may refuse service if you fail to pay anycopayments but only as long as refusing service due to failure to pay copayments is

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You may get these services: Healthy PlanNo limits

Healthy Plus PlanNo Limits

BENEFIT PLAN COMPARISON CHART

Ambu lan ce Services


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No limits

2 visits per Calendar Year (CY)

3 visits per CY

Limited to Schizophrenia (1 per wk)No Limits9 visits per CYCovered *$1000 per CYNo LimitsLimited to individuals with aphakia2 eyeglass frames per CY4 eyeglass lenses per CY4 contact lenses per CY$350 per CYNo Limits (except for dental service asdefined above)No Limits60 visits per CY

No LimitsRespite care may not exceed a total of 5days in a 60-day certification period.5 visits per CY30 days per CY2 non-emergency admissions per CY1 admission per CY

30 days per CYNOT COVERED

No Limits31 visits per CY$1000 per CY

One visit per day/7 visits per weekNo Limits1 visit per CYOpiate Detox: 42 visits per CYChemotherapy/drug-free visits: 3 visitsper 30 days9 visits per CY30 visits per CY4 hours per day/ 900 hours per CY4 visits per CY4 visits per CY6 prescriptions per monthNo Limits540 hours per CY6 tests per CY

Initial training for home dialysis is limitedto 24 sessions per patient per CY.Backup visits to the facility limited to nomore than 75 per CYNOT COVERED

5 visits per CYNo Limits

No Limits

No Limits

No Limits

No LimitsNo Limits10 visits per CYCovered *No LimitsNo LimitsLimited to individuals with aphakia2 eyeglass frames per CY4 eyeglass lenses per CY4 contact lenses per CYNo LimitsNo Limits (except for dental services asdefined above)No LimitsUnlimited first 28 days; 15 days per month following.No LimitsRespite care may not exceed a total of 5days in a 60-day certification period.No LimitsNo LimitsNo LimitsNo Limits

No LimitsNo Limits

No LimitsNo Limits$2500 per CY does not includediabetic supplies when provided by apharmacyNo LimitsNo Limits1 visit per CYNo Limits

No LimitsNo LimitsNo LimitsNo LimitsNo LimitsNo LimitsNo LimitsNo LimitsNo Limits

Initial training for home dialysis is limitedto 24 sessions per patient per CY.Backup visits to the facility limited to nomore than 75 per CYNo Limits

No LimitsNo Limits

Ambu lan ce Services(emergency)

Ambu latory s urgical cen ter s(ASCs)CRNP

ClozapineCrisis supportChiropractic servicesDental servicesDurable medical equipmentEmergency servicesEyeglasses/contact lenses

Laboratory testsFederally qualified healthcenter/rural health c linicFamily PlanningHome health care

Hospic e Care

Independent ClinicInpatient drug and alcoholInpatient acute hospitalInpatient rehabilitation hospital

Inpatient psych iatric hospitalIntermediate care facility(IID/ORC)Maternity ServicesMobile mental health treatmentMedical supplies

Methadone MaintenanceNutritional supplementsOptometrist servicesOutpatient drug and alcoholservices

Outpatient hospit al clinicOutpatient psychiatric c linicPeer supportPhysician Office visitsPodiatrist servicesPrescription drug sPrimary care provider Psychiatric partial hospitalRadiology (X-rays, MRIs, CTs)

Renal dialysis (kidneytreatment)

Residential Treatment Facility(Non-Hospital Residential D&A)Short Proc edure Unit (SPU)Skilled nursing facility


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Complaint Exhibit E 13 of 20


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Documents

Mendez v Mackereth Complaint