Legal aid attorneys are trying to understand why the Department of Social Services is denying, without explanation, Medicaid patients’ attempts to get pre-approved for certain drugs.
Usually the reason for denial is clear-cut — this particular drug does not suit the patient’s illness, or their medical provider failed to fill out the form correctly.
But according to legal aid attorneys, the department has consistently issued notices that offered no real reason at all — an omission they say has likely resulted in hundreds of low-income patients being denied medication altogether.
“The notices we have seen fail to tell Medicaid enrollees the reason for the negative action and the specific regulatory basis for the action,” Jean Mills Aranha, of Connecticut Legal Services, and Sheldon Toubman, of New Haven Legal Assistance Association, wrote in a May letter to the department’s legal counsel.
“They do not meet the most basic requirements of the 14th Amendment’s Due Process Clause and federal due process Medicaid regulations,” the letter states.
Current regulations mandate that the written notice must provide recipients with a “timely and adequate notice detailing the reasons for a proposed determination,” as well as a “detailed individualized explanation of the reason(s) for the action being taken.”
But the DSS-issued denial notices the attorneys included in their letter that simply stated “PDL PA Denied” — or “Preferred Drug List Prior Authorization Denied.”
“Some of these individuals may then have been prescribed alternative drugs, which may or may not have been as effective as the original drug for which PA was sought,” the letter states. “Others … may have simply gone without any treatment at all.”
The attorneys requested the department stop issuing denial notices that use “PDL PA Denied” as a reason, and to issue corrective notices to all patients who received notices of the same type.
But the department said they believed this to be excessive.
In a July 10 reply letter, while promising to ensure that the revised notices “clearly articulate the reasons and regulatory basis for the denial of prior authorization request,” the department said they would not issue corrective notices to the Medicaid enrollees who received denials.
They said they believed that sending out such notices would “only confuse” patients, and that most of the previous denials had already been granted authorization.
However, after receiving another letter on July 17 from the Office of the Healthcare Advocate, DSS agreed to begin looking into how many patients received denial notices and were not subsequently granted prior authorization.
As of now, the department has not yet provided any information on when the faulty notices began to be issued, or how many patients received them. They have not yet confirmed whether they’ve begun to issue these updated notices, but originally said they expected them out by Aug. 1.
“In the event that there are cases where the client did not receive authorization or a therapeutically equivalent drug, DSS or its contractor will reach out to those individuals and recommend that they ask their providers to send another prior authorization request for that drug,” Brenda Parella, the department’s legal director, said in a follow-up letter.
An example they provided of an updated denial reason tells the patient that their provider “did not fill out all the sections of the prior authorization form,” and suggests the patient contact their provider and ask them to resubmit the form.
But the attorneys don’t think this explanation will cut it.
“The drugs they are receiving may not be as effective as the drugs for which authorization was sought,” Arhana and Toubman said in another letter to the department. “Under federal Medicaid law and the state’s Medicaid medical necessity definition, they are entitled to the more effective drugs.”
They also cited a number of issues they saw with the updated denial notice from DSS. They said the example notice provided to them still failed to provide the necessary specificity mandated by federal law.
DSS said it’s still working on obtaining the information about denials the attorneys requested.