Q & A: ICF-MR level care and “persons with related conditions”

Question: Ms. R. is a 24-year-old woman who came to my office after she received a notice terminating her from our state’s Medicaid home and community based waiver for the mentally retarded (HCBW-MR). Ms. R has been diagnosed with Asperger’s Disorder. While sharing characteristics with autism, Asperger’s is a specific type of Pervasive Developmental Disorder characterized by social isolation and impairments in social interaction and communication. Ms. R’s speech and motor behavior are also affected. The State no longer considers Ms. R’s diagnosis of Asperger’s Disorder to be a form of mental retardation and, thus, says she is not eligible for care in an intermediate care facility for the mentally retarded (ICF-MR) or, consequently, for the HCBW-MR. I have contacted her treatment team and a Medicaid worker and was told that the decision was not based on the facts of the particular limitations experienced by Ms. R. In fact, the treatment team indicated that there is no question but that Ms. R. has significant limitations in at least four activities of daily living and that she needs active treatment. How can we challenge the termination?

Brief Answer: You should immediately request an administrative fair hearing and ask that Ms. R.’s benefits be continued pending the decision on her claim. You should argue that Ms. R. qualifies for ICF-MR services, and thus the HCBW-MR, because, even if she does not qualify as an individual with mental retardation, she is a “person with related conditions” as defined by federal Medicaid laws. As a result, she is eligible for ICF-MR level care and her Medicaid HCBW-MR service should not be terminated.

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