U.S. Court Rules Florida Medicaid Must Cover All Medically Necessary Services for Children

A U.S. district court permanently enjoins Florida from denying coverage for incontinence diapers to EPSDT-eligible children, ruling that where federal law requires the provision of medically necessary services to children on Medicaid, the state cannot refuse to provide those services, even if the services are not in the state's Medicaid plan. Smith v. Benson (S. Dist. Fla., No. 09-21543-CIV-GOLD/MCALILEY, Jan. 27, 2010).

Sharett Smith, a 17-year-old Medicaid recipient with developmental disabilities and cerebral palsy, was unable to control her bladder and bowel movements. Sharett's doctor found that incontinence diapers were medically necessary to prevent skin irritation and infection. Two different Medicaid durable medical equipment suppliers refused to fill the prescription, explaining that Florida Medicaid law specifically prohibited coverage of incontinence supplies.

Through her father, Sharett filed an action against the Florida Agency for Health Care Administration, arguing that Florida's blanket prohibition on Medicaid payment for incontinence supplies for children violated federal Medicaid law. Specifically, Sharett claimed that federal law requires that all children eligible for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) receive any service that states are permitted to cover under Medicaid so long as the service is necessary to treat a medical condition identified by an EPSDT screen, regardless of whether the service is included in the state's Medicaid plan. In its objection to Sharett's motion for summary judgment, the state claimed that the family had not presented enough evidence to show that the diapers were medically necessary, among other assertions.

The U.S. District Court for the Southern District of Florida grants Sharett's motion for summary judgment and issues an injunction permanently enjoining the state from issuing blanket denials of EPSDT recipients' requests for incontinence supplies. The court finds that "because incontinence supplies are described in the medical assistance category of 'home health care services', they must be provided to EPSDT eligible children if necessary to correct or ameliorate a condition discovered by screening, whether or not such services are covered under the State plan. Accordingly, while the Rule's exclusion of 'diapers and incontinence briefs of any kind' may be a proper limitation on the scope of home health care services as they apply to recipients over 21 years of age, to the extent that the exclusion applies to EPSDT benefits without an appropriate exception, the Rule is in violation of the Medicaid Act."

For the full text of this decision, go to: https://attorney.elderlawanswers.com/full-text-of-opinion-in-smith-v-benson-sdistfla-no-09-21543-civ-goldmcaliley-jan-27-2010-8049

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