A managed care subcontractor obtained a temporary injunction this week against the Social Services Department, stopping the disclosure of documents related to how “medical neccesity” is determined.
McKesson Health Solutions, LLC, a subcontractor for WellCare, was granted the temporary injunction Monday before opposing attorneys were able to object.
Legal aid attorneys, with the help of the Attorney General’s office, have been pushing WellCare and three other managed care organizations that run the state Medicaid program to disclose how it determines “medical necessity” for the state’s neediest population.
Attorney General Richard Blumenthal said Wednesday that “we had almost no notice of the injunction,” but he said the state will be ready to vigorously contest the trade secret claim and oppose a preliminary injunction on May 7 when they go to court.
The complaint for the injunction filed in Hartford Superior Court argues that the software program used to determine medical necessity is a trade secret and exempt from disclosure under the state’s Freedom of Information Act.
Blumenthal said he sees no reason for withholding the documents under the trade secret exemption, and told DSS it was okay to release the documents. DSS had initially hesitated for fear of a trade secret lawsuit by WellCare.
But WellCare seems to have found away around it by getting McKesson, its subcontractor, to file suit.
New Haven Legal Aid Attorney Sheldon Toubman said the state explicitly requires WellCare to enforce the state’s medical necessity standards with all of its subcontractors.
WellCare has released some of the information the state has requested.
But of the few criteria advocates have seen, they said there is a significant difference in what WellCare covers and what is supposed to be covered under state rules.
Some examples include:
-Denying needed orthodontic braces to children with a “severe deviation” in their teeth, because their case doesn’t meet a numerical score even though state regulations require treatment for all such deviations.
-Denying medical equipment needed by children with sleep apnea based on WellCare’s “Health Plan criteria,” regardless of the broader DSS criteria.
-Denying access to medications unless they are necessary to sustain the life of an enrollee, even though the DSS definitions more broadly require payment for health care needed “to assist an individual in attaining or maintaining an optimal level of health.”