Child keeps in-home nursing hours

Miranda Wrobel had just turned 7. She lived at home with her parents, Michaele "Mike" Monaghan and Rand Wrobel. Her brother, Jordan is two years older. Injured during birth, Miranda relied on 56 hours a week of in-home nursing care. Her parents cared for her the rest of the time, including all overnight care.

Notice cuts nursing hours

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program ways paying for nursing care to monitor Miranda's 20 to 30 seizures a day, and to give her the oxygen support and medications she needed. Miranda had frequent fever spikes and episodes of dysautonomia - a condition that caused her to hyperventilate and turn blue on one side of her body.

In July 2003, a Notice of Action from the Department of Health Services (DHS) In-Home Operations (IHO) cut Miranda's nursing hours from 56 hours a week to 45. The notice claimed that Miranda no longer met the level of care to justify 56 hours a week.

Family appeals notice

"Level of care" means the kind of facility Miranda would need if she were placed out of her home. Medi-Cal says that EPSDT regulations limit the number of in-home nursing hours to what it would cost Medi-Cal to care for a person in a facility. In Miranda's case, the issue was whether she was:

  • Still at the pediatric subacute level of care; or
  • At the level of an Intermediate Care Facility Developmental Disability-Nursing, which provides fewer services.

The Wrobel family appealed the notice. Elissa Gershon, a staff attorney in PAI's Oakland office, represented Miranda at an administrative hearing. She argued that Miranda's condition had not improved, so a reduction in the level of care was not warranted.

There must be an actual facility

Gershon also argued that DHS had not sent a proper notice, as required under the settlement in T.L. v. Belshe. That decision says that if the state wants to cut someone's level of care for in-home services, the state must identify an actual facility, at the proposed level of care, within one hour of the family home, that is able and willing to take her. Diana Honig, also an attorney in the Oakland office, worked with Gershon on Miranda's case.

Ruling in Miranda's favor, theMay 8, 2008s condition had not improved, and had in fact worsened;

  • Continuation of her nursing hours at the pediatric subacute level of care was justified; and
  • The state's notice was proper.

    • IHO denied TAR

    After the ruling came through, IHO again denied the nursing agency's Treatment Authorization Request (TAR). EPSDT staff said the judge's decision only applied to the prior year's TAR. It looked like they would have to fight the same fight all over again.

    Legislators respond to plea for help

    But Gershon assured the Wrobels that the denial was wrong, and urged them to write to their state representatives in Sacramento. They did. Assemblywoman Wilma Chan and Senator Don Perata both responded. Their offices contacted the Wrobels and got to work.

    TAR approved

    Their efforts convinced EPSDT staff to approve the TAR. Legislative staff kept working on the issue because they found other families whose hours had also been cut.

    "It was awesome"

    "It was awesome," said Monaghan. "I was contacted by both legislative offices within days. Both Marty Doyle (Senator Perata's office) and Joanne Parenti (Assemblywoman Wilma Chan's office) were terrific. In the end, the head of IHO, Greg Hughes, called me and said she had approved the TAR, and would call both legislative offices and the nursing agency (if that was OK with me)."

    "Those guys were great!"

    A new TAR was submitted, and Marty Doyle stayed involved. "She says she will call everyone to make sure they do what is necessary," said Monaghan. "Between Elissa and Diana and Marty and Joanne we got through it. Those guys were great!"