20231207_C363697_43_363697.Opn.Ord.Pdf

CourtMichigan Court of Appeals
DecidedDecember 7, 2023
Docket20231207
StatusUnpublished

This text of 20231207_C363697_43_363697.Opn.Ord.Pdf (20231207_C363697_43_363697.Opn.Ord.Pdf) is published on Counsel Stack Legal Research, covering Michigan Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
20231207_C363697_43_363697.Opn.Ord.Pdf, (Mich. Ct. App. 2023).

Opinion

If this opinion indicates that it is “FOR PUBLICATION,” it is subject to revision until final publication in the Michigan Appeals Reports.

STATE OF MICHIGAN

COURT OF APPEALS

CB, by Next Friend and Guardian DEBBIE FOR PUBLICATION MACIKA, December 7, 2023 9:05 a.m. Plaintiff-Appellant,

v No. 363697 Livingston Circuit Court LIVINGSTON COUNTY COMMUNITY MENTAL LC No. 22-000284-AW HEALTH,

Defendant-Appellee.

Before: HOOD, P.J., and JANSEN and FEENEY, JJ.

HOOD, P.J.

Plaintiff, CB, through his mother and guardian, Debbie Macika, appeals by right the trial court’s order denying his petition for a writ of mandamus related to Medicaid-funded benefits. Defendant, Livingston County Community Mental Health (LCCMH), eventually provided the services that CB sought to compel through mandamus; some before the trial court issued its order, and some while this appeal was pending. This rendered the issue of mandamus moot, but not damages. We affirm in part, reverse in part, and remand for further proceedings to address damages.

I. BACKGROUND

This case arises out of LCCMH’s failure to provide CB certain services to which CB was entitled and which LCCMH was required to provide under Medicaid. The underlying facts of this case are not largely in dispute.

CB is a man with cerebral palsy, an intellectual disability, and speech impairments. He is quadriplegic and cannot talk. His mother, Macika, is his guardian. Because of these disabilities, CB was authorized to receive certain Medicaid-funded services, including Community Living Support (CLS) and “respite care services.” CLS services are meant to help individuals like CB

-1- remain in their communities and avoid institutionalization.1 Respite care services are provided intermittently to relieve the recipient’s family during times when they would be providing unpaid care.2 Depending on a beneficiary’s plan of service, respite care services can be provided in licensed foster care homes, licensed camps, or as in CB’s case, in the home.3 This Court has previously summarized these Medicaid-funded services as follows:

Michigan offers funding and support to qualifying individuals with disabilities to help them live independently in their home communities instead of in institutionalized care facilities. This program is called Community Living Support (CLS) and is authorized by a Medicaid waiver from the federal government called the Habilitation Supports Waiver (HSW). The CLS program furthers participants’ “self-determination by allowing them to structure their own support services based on their medical needs.” The HSW is financed through “capitation procedures,” which “means that the federal government provides [prepaid inpatient health plans (PIHPs)] . . . with a fixed amount of funding for each person participating in the CLS program, regardless of how many services the entity ultimately provides to the recipient. The PIHP then determines how to allocate these funds to recipients.” [Wiesner v Washtenaw Co Community Mental Health, 340 Mich App 572, 577; 986 NW2d 629 (2022) (citations omitted; alteration in original).]

The CLS and respite services were part of CB’s “Individual Plan of Service (IPOS). Individuals like CB, who choose to receive CLS services, go through a “person-centered planning process,” which results in an IPOS and a corresponding budget for CLS services. See Wiesner, 340 Mich App at 578. “The IPOS describes the services that have been deemed ‘medically necessary’ for each recipient based on criteria defined in Michigan’s Medicaid Provider Manual.” Id. (quotation marks and citation omitted). The budget ostensibly reflects the costs of the services and supports necessary to implement the IPOS. Here, this amounted to 25 hours of CLS and 6 hours of respite services each week. CB’s respite services were to be in-home, as opposed to a foster care center or camp. These services were authorized to start in June 2021.

LCCMH is a community mental health service provider, and was the service provider responsible for CB’s services. It had a prepaid inpatient health plan (PIHP) contract with the Michigan Department of Health and Human Services (MDHHS), the state department responsible for administering Medicaid funds and programing in Michigan, to provide all medically necessary

1 Michigan Medicaid Provider Manual, Behavioral Health and Intellectual and Developmental Disability Supports and Services, p 111-112. Available at https://www.mdch.state.mi.us/dch- medicaid/manuals/MedicaidProviderManual.pdf. 2 Michigan Medicaid Provider Manual, Behavioral Health and Intellectual and Developmental Disability Supports and Services, p 126. Available at https://www.mdch.state.mi.us/dchmedicaid/manuals/MedicaidProviderManual.pdf. 3 Michigan Medicaid Provider Manual, Behavioral Health and Intellectual and Developmental Disability Supports and Services, p 127. Available at https://www.mdch.state.mi.us/dchmedicaid/manuals/MedicaidProviderManual.pdf.

-2- services to CB. This Court has previously described the regulatory and organizational background for this relationship:

The MDHHS “contracts with regional prepaid inpatient health plans (‘PIHPs’), which are public managed care organizations that receive funding and arrange and pay for Medicaid services.” The MDHHS “has supervisory and policymaking authority over the PIHPs and must ensure that PIHPs retain oversight and accountability over any subcontractors. PIHPs subcontract with community organizations that provide or arrange for mental health services for recipients . . . .” [Wiesner, 340 Mich App at 577 (citations omitted; alteration in original).]

In this case, LCCMH was a community mental health service provider and mental health authority that contracted with MDHHS and one of Michigan’s ten regional PIHPs to provide Medicaid- funded services to, among others, adults with mental illness or developmental disabilities who lived in Livingston County.4

There is no dispute about LCCMH’s intended function or that it was the provider responsible for providing CB with services for his disabilities. But CB did not receive his authorized services for approximately two years due to LCCMH’s failure or inability to find suitable providers. Although the services were authorized to start in June 2021, CB did not receive CLS services until September 2022, and at-home respite care services until June 2023.

Because of the delay, in March 2022, CB sought and received a “Medicaid Fair Hearing” before an administrative law judge (ALJ). MDHHS delegates authority to the Michigan Office of Administrative Hearings and Rules to hear and issue decisions on behalf of MDHHS. A “Medicaid Fair Hearing” is an administrative hearing that allows beneficiaries (or providers) to contest actions taken by MDHHS, their contracted agencies, or managed care entities. During this process, LCCMH stipulated that the CLS and respite care services at issue were medically necessary and it had not provided them.

On July 8, 2022, the ALJ issued a written decision granting summary disposition in favor of CB. After that decision, LCCMH was required to provide the services as promptly and expeditiously as possible, but not later than 72 hours after the order. See 42 CFR § 428.424(a). In a certification order dated July 18, 2022, one week after the 72-hour deadline, LCCMH stated that it had not been able to comply with the decision and order and that its expected compliance date was “unknown.”

In August 2022, in an effort to enforce the ALJ’s order, CB filed a complaint for mandamus and ex parte motion to show cause. Through the complaint, CB requested three specific forms of relief.

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