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Court Decides in Favor of Medicaid Waiver Applicant

Jul 30, 2011

Recently, a disabled adult's mother came to my office with a question: What difference does it make when my son was diagnosed as Intellectually Disabled? He is, was and always will be disabled.

Medicaid had ruled that her son had to be diagnosed as Intellectually Disabled before turning 18 years old in order to qualify for the MR/ID (Mentally Retarded/Intellectually Disabled) Waiver benefit program.  Medicaid stated that since her son had missed this arbitrary 18 years old deadline, he would be denied a MR/ID Waiver.

What was a mother to do?  And now, as lawyer of record, what was I to do?  Allow me to elaborate:

When her son was 10 years old, he scored 71, in the borderline range of intellectual functioning on the Stanford-Binet Intelligence Test.  When he reached 18 years and 1 month, he was re-tested and scored 54.  This score officially classified him as Intellectually Disabled.

Score in hand, his primary caregivers, his Parents, applied for an MR/ID Waiver.  the MR/ID Waiver is a Medicaid program that supplies residential, day, and pre-vocational support to the Intellectually Disabled.  The Waiver is designed to be an alternative to institutionalization.  The Waiver provides housing to eligible individuals.  

His parents fully expected their Waiver Application to be processed quickly since their ages qualified them as Urgent Applicants.  Instead, Medicaid noted that it wasn't until their son was 18 years and 1 month old, that he scored Intellectually Disabled. The prior, 10 year old test, found their son as borderline intellectual functioning.  Medicaid ruled that that the Waiver Program was designed to serve those who became Intellectually Disabled prior  to turning 18, so the late-occurring intellectual disability disqualified him for the Waiver Program.

His mother insisted that her son's Intellectual Disability was not late occurring.  Her son's Vocational Rehabilitation Counselor agreed.  She stated that he did not suddenly lose the 17 points on turning 18, but had a gradually decreasing IQ, losing about 2 IQ points a year. 

I filed an argument in Circuit Court stating that Medicaid law did not restrict Mediciad from using the IQ test results after the age of 18.  The judge agreed.   The Court required Medicaid to use all IQ test results when making its consideration.  Medicaid could not use an arbitrary diagnosis date to deny my client's son a Medicaid Waiver. 
With this instruction from the Court, Medicaid quickly found my client's son eligible for the MR/ID Waiver. 

It is unknown how many other applicants have been unfairly denied this Waiver based on this Medicaid interpretation of the law.  But if they have been so denied they should apply again and if denied appeal the decision.


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