NCLEJ Sues to Stop Michigan Medicaid “Hamster Wheel”

Medicaid recipients have long had rights to “fair hearings” to challenge actions affecting their
benefits. According to a new lawsuit, however, recipients in Michigan cannot get relief from those hearings, even
when they win.

The suit, filed by attorneys for Michigan Protection & Advocacy Services, Inc. (MPAS), the National Center for
Law and Economic Justice (NCLEJ) and Legal Services of South Central Michigan (LSSCM), says that the
administrative law judges (ALJs) presiding over fair hearings lack the power to order the agency to grant the
benefits it had wrongfully denied. All they can do is send the case back to the agency to “reassess” the recipient.
And when the agency comes back with the same decision on reassessment—as it often does—all the recipient
can do is ask for another fair hearing, where the same thing will happen again. This is the Michigan Medicaid
“Hamster Wheel”: recipients run and they run and they run, but they never get anywhere.

Named Plaintiff Kevin Wiesner lives with various disabilities, and he relies on Medicaid-funded community
living supports (CLS) to stay in the community. In 2019, he challenged the CLS budget provided by Washtenaw
County Community Mental Health (WCCMH), and the ALJ held in his favor in every respect: The budget was
insufficient to meet Kevin’s medical needs, it had been insufficient since at least 2015, and at least a certain,
specific amount was required to make it sufficient. But the ALJ did not—because he said he could not—order a
budget of that amount. Instead, he told WCCMH to “reassess” Mr. Wiesner’s needs. To no one’s surprise,
WCCMH’s “reassessment” ignored the ALJ’s determination and denied Mr. Wiesner any increase at all.
“For more than 50 years, the Constitution and federal statutes have guaranteed public benefit recipients the right
to an impartial determination of their benefits,” said Ed Krugman, a senior attorney at NCLEJ, “The Michigan
Hamster Wheel makes a mockery of that right. Kevin Wiesner fought for the services he needs, and he won, but
he got precisely nothing. That is a travesty.”

“The Medicaid Fair Hearing System is supposed to give recipients the right to challenge actions that negatively
affect their benefits,” said Kyle Williams, legal director for MPAS. “If administrative law judges are only allowed
to order reassessments, they can never win those challenges, because the reassessment decision is ultimately in
the hands of the agency that took the negative action in the first place.”

Nick Gable, attorney for LSSCM, offered a similar thought. “The Medicaid fair hearing “Hamster Wheel” has
been a problem for years, to the point that appeals challenging personal care or home and community-based
support services denials are rendered futile. A legal challenge to the Hamster Wheel is overdue.”

The suit names WCCMH, Community Mental Health Partnership of Southeast Michigan, their directors, and
Michigan Department of Health and Human Services Director Robert Gordon as defendants. The requested relief
seeks to end the practice of ALJs remanding cases without ordering specific relief for Medicaid recipients.

Press Release for Michigan Medicaid suit.