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Medicaid Beneficiary Bears Burden of Proving That State's Reduction of Nursing Services Was Unreasonable
The 11th Circuit Court of Appeals rules that a Medicaid recipient whose in-home nursing care hours were reduced by the state despite her doctor's certification that they were medically necessary must prove at trial that the state acted unreasonably. Moore v. Reese (11th Cir., No. 10-10148, April 7, 2011).
Anna C. Moore, a 16-year-old Medicaid beneficiary who suffers from multiple disabilities, requires 24-hour care. Anna received 94 hours of in-home nursing care based on her doctor's certification that such care was necessary, but the Georgia Department of Community Health, relying on an evaluation by its own medical staff, attempted to reduce the care to 84 hours. Anna filed a civil rights suit in federal court and a U.S. District Court granted her motion for summary judgment, finding that the state could not override her physician's certification of medical necessity. The 11th Circuit reversed the District Court's decision and remanded the case for further consideration, but on remand the District Court again sided with Anna, granting her second motion of summary judgment, this time stating that the state could overrule a treating physician's determination of medical necessity only in cases of fraud or abuse or to determine whether the services are within reasonable standards of medical care. The state appealed again.
On appeal, the state argued that it was entitled to limit the scope of private duty nursing services as long as the reduced services were sufficient under the Early and Periodic Screening, Diagnosis and Treatment requirements. Anna alleged that her treating physician's determination was entitled to deference under federal law.
The 11th Circuit reverses the District Court for a second time and remands the case for a trial on the merits. In an exhaustive 90-page opinion, the court explains that under federal law, "a state 'can review the medical necessity of treatment prescribed by a doctor on a case-by-case basis,' and may present its own evidence of medical necessity in disputes between the state and Medicaid patients." The court goes on to rule that "the plaintiff will have to show [at trial] that the limits the state imposed on her physician's discretion in reducing her nursing hours . . . are not reasonable -- that those limits are not sufficient in amount, duration and scope to reasonably achieve the treatment's purpose."
A roundup of elder law news and practice development articles culled from news sources across the nation during the week of May 28, 2025, to June 2, 2025.
Minnesota DHS Entitled to Recover Capitation Payments
The Minnesota Supreme Court held that the Minnesota Department of Human Services (DHS) was entitled to recover capitation payments made to a managed care organization on the decedent’s behalf for long-term care services provided through the state’s Medicaid program from...
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Medicaid Beneficiary Bears Burden of Proving That State's Reduction of Nursing Services Was Unreasonable
The 11th Circuit Court of Appeals rules that a Medicaid recipient whose in-home nursing care hours were reduced by the state despite her doctor's certification that they were medically necessary must prove at trial that the state acted unreasonably. Moore v. Reese (11th Cir., No. 10-10148, April 7, 2011).
Anna C. Moore, a 16-year-old Medicaid beneficiary who suffers from multiple disabilities, requires 24-hour care. Anna received 94 hours of in-home nursing care based on her doctor's certification that such care was necessary, but the Georgia Department of Community Health, relying on an evaluation by its own medical staff, attempted to reduce the care to 84 hours. Anna filed a civil rights suit in federal court and a U.S. District Court granted her motion for summary judgment, finding that the state could not override her physician's certification of medical necessity. The 11th Circuit reversed the District Court's decision and remanded the case for further consideration, but on remand the District Court again sided with Anna, granting her second motion of summary judgment, this time stating that the state could overrule a treating physician's determination of medical necessity only in cases of fraud or abuse or to determine whether the services are within reasonable standards of medical care. The state appealed again.
On appeal, the state argued that it was entitled to limit the scope of private duty nursing services as long as the reduced services were sufficient under the Early and Periodic Screening, Diagnosis and Treatment requirements. Anna alleged that her treating physician's determination was entitled to deference under federal law.
The 11th Circuit reverses the District Court for a second time and remands the case for a trial on the merits. In an exhaustive 90-page opinion, the court explains that under federal law, "a state 'can review the medical necessity of treatment prescribed by a doctor on a case-by-case basis,' and may present its own evidence of medical necessity in disputes between the state and Medicaid patients." The court goes on to rule that "the plaintiff will have to show [at trial] that the limits the state imposed on her physician's discretion in reducing her nursing hours . . . are not reasonable -- that those limits are not sufficient in amount, duration and scope to reasonably achieve the treatment's purpose."
Medicaid Beneficiary Bears Burden of Proving That State's Reduction of Nursing Services Was Unreasonable
<p>The 11th Circuit Court of Appeals rules that a Medicaid recipient whose in-home nursing care hours were reduced by the state despite her doctor's certification that they were medically necessary must prove at trial that the state acted unreasonably. <a href="https://www.ca11.uscourts.gov/opinions/ops/201010148.pdf"><i>Moore v. Reese</i></a> (11th Cir., No. 10-10148, April 7, 2011).</p><p>Anna C. Moore, a 16-year-old Medicaid beneficiary who suffers from multiple disabilities, requires 24-hour care. Anna received 94 hours of in-home nursing care based on her doctor's certification that such care was necessary, but the Georgia Department of Community Health, relying on an evaluation by its own medical staff, attempted to reduce the care to 84 hours. Anna filed a civil rights suit in federal court and a U.S. District Court <a href="https://attorney.elderlawanswers.com/-i-moore-v--medows--i---n-d-ga---no-1-c7-cv-631-twt--june-4--2008--13423">granted her motion for summary judgment</a>, finding that the state could not override her physician's certification of medical necessity. The 11th Circuit reversed the District Court's decision and remanded the case for further consideration, but on remand the District Court again sided with Anna, granting her second motion of summary judgment, this time stating that the state could overrule a treating physician's determination of medical necessity only in cases of fraud or abuse or to determine whether the services are within reasonable standards of medical care. The state appealed again.</p><p>On appeal, the state argued that it was entitled to limit the scope of private duty nursing services as long as the reduced services were sufficient under the Early and Periodic Screening, Diagnosis and Treatment requirements. Anna alleged that her treating physician's determination was entitled to deference under federal law.</p><p>The 11th Circuit reverses the District Court for a second time and remands the case for a trial on the merits. In an exhaustive 90-page opinion, the court explains that under federal law, "a state 'can review the medical necessity of treatment prescribed by a doctor on a case-by-case basis,' and may present its own evidence of medical necessity in disputes between the state and Medicaid patients." The court goes on to rule that "the plaintiff will have to show [at trial] that the limits the state imposed on her physician's discretion in reducing her nursing hours . . . are not reasonable -- that those limits are not sufficient in amount, duration and scope to reasonably achieve the treatment's purpose."</p><p>For the full text of this decision, go to: <a target=_blank href=" https://www.ca11.uscourts.gov/opinions/ops/201010148.pdf"> https://www.ca11.uscourts.gov/opinions/ops/201010148.pdf</a></p>
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