Assisted living residents Betty Hilleger and Geraldine A. Saunders applied for a Medicaid assisted living waiver from the state of Ohio to pay for home health care. The state found them eligible for benefits, but it denied them retroactive benefits because the state provides only prospective coverage from the date the applicant is enrolled in the waiver program.
Ms. Hilleger and Ms. Saunders filed a class action lawsuit against the state, arguing that Ohio is violating federal law by providing only prospective assisted living waiver benefits. Federal law specifically requires that retroactive benefits be provided during the three months before the application if the applicant was eligible for benefits during that time. The state argued that eligibility for assisted living waiver benefits is prospective only, because it requires, among other things, a face-to-face assessment of the applicant. Because these specific Ohio rules mean that an individual applicant cannot be eligible for benefits prior to the face-to-face assessment, individuals cannot be enrolled retroactively in the waiver program.
The United States District Court, Southern District of Ohio, agreed that Ohio is violating federal law and granted summary judgment to Ms. Hilleger and Ms. Saunders certifying the class action. The Court held that the clear language of federal Medicaid law requires the state to provide retroactive benefits. According to the court, "there is nothing about a face-to-face assessment or the use of the assessment tool that prevents a retrospective determination of eligibility." In other words, state rules cannot be used in a manner to deny the applicant what federal law plainly permits.
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