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Grier v. Goetz

Jodie and her son, Jonathon. Jodie is a Grier class member and multiple sclerosis patient who struggled to get her medications due to prior authorization issues. Photo by Abby Whisenant, volunteer photographer

• Your 1-year-old daughter, Lauren, has a heart defect. The doctors all say she needs surgery to survive, but the HMO says she doesn’t need it and refuses coverage.

• Your 15-year-old son, Mike, suffers a head injury in an accident.  His doctors order treatment in a facility that specializes in treating teenagers with brain injuries. No one denies the need, but Mike remains without the care for months, as the state’s contractors bicker among themselves about which is responsible.

• You are a 23-year-old woman who suffers from bipolar disorder. You are supposed to receive ongoing therapy and medication but have not been able to get it because of gaps in the TennCare system. You have been hospitalized for the sixth time this year on an emergency basis to prevent your suicide. After two days, TennCare says your time is up and you must be discharged. You are terrified that, without any assurance of outpatient care, you will relapse into suicidal depression.

Previously known as Daniels v. Wadley, this case produced a landmark 1996 ruling on the right of Medicaid patients to contest denials of care by their managed care plans. However, TennCare and its private contractors refused to fully implement the order, and subsequent negotiations failed to bring about compliance. In 1999, marathon negotiations mediated by the federal court produced a comprehensive agreement, backed by court order, which provides appeal protections to TennCare enrollees. The order subjected HMO denials to heightened scrutiny and imposed substantial penalties for future noncompliance. It also creates special protections for the mentally ill and those with chronic illness. This case vividly demonstrates the necessity of ongoing advocacy for the poor, even after they win in court.

In 2003, another change to the settlement agreement suspended the 14-day provision for the dispensing of prescription drugs not onTennCare’s formulary and replaced it with a 3-day limit. This change saved TennCare over $150 million annually.

The settlement also provides additional protections for enrollees who are in a youth development center and for enrollees who successfully appeal a denial of services.

Jewell and her daughter, Drayma. Jewell was both a Grier and Rosen class member. She has multiple health issues and had problems getting her medical care. With help from TJC, she was able to get her medical care until she became one of the thousands of people who were cut from TennCare. Photo by Jay Watson, volunteer photographer

In 2005, the state sought to have the protections of Grier stripped from the entire TennCare population. After a three-week trial, the Court granted the state many of the changes it sought. (see Aug and Nov 2005 orders below).

In return for relief from the promises state officials made in 2003, the Court received assurances that the state would do two things:

• implement “soft limits” on medicine (a process by which enrollees who really need more than 5 prescriptions per month can access the additional medically necessary prescriptions); and
• spare 100,000 TennCare enrollees’ coverage.

It remains to be seen whether the state will honor either of these promises.

Daniels v. Wadley, 926 F. Supp. 1305 (M.D. Tenn. 1996), vacated in part and remanded Daniels v. Menke, 145 F.3d 1330 (6th Cir. Tenn. 1998); Tenn. Assoc. of Health Maintenance Organizations, Inc. v. Grier, 262 F.3d 559 (6th Cir. 2001).

Revised Consent Decree [pdf] (October 1, 2003)

Doc. 1256 [pdf] (August 3, 2005): Revised order granting in part and denying in part the defendants’ motion to modify the Revised Consent Decree.

Doc. 1261 [pdf] (August 9, 2005): Order regarding Defendants’ Motion to Amend which preserves the right to appeal where no prior authorization has been sought.

Doc. 1282 Part 1, pgs. 1-59 [pdf] and Doc. 1282 Part 2, pgs. 60-106 [pdf] (November 15, 2005): Memorandum opinion regarding modifications to the Revised Consent Decree.

Doc. 1328 [pdf] (January 31, 2006): Granting Plaintiffs’ Motion to Clarify.

Doc. 1345 [pdf] (March 15, 2006): THA’s Motion to Amend Judgment.

Doc. 1347 [pdf] (March 23, 2006): Order for both parties to adopt the Court’s revision to Paragraph C7b of Consent Decree and State must Modify or Explain Medical Necessity Rules.

Doc. 1394 [pdf] (July 14, 2006): Memorandum Order clarifies amendments to consent decree, including notice requirements for pharmacy and deadlines for when TennCare may correct a notice.

Doc. 1404 Part 1 [pdf], Part 2 [pdf], Part 3 [pdf], and Part 4 [pdf] (July 28, 2006): Defendants Proposed Order with Consent Decree Changes.  The proposed changes have not yet been approved by the Court. Plaintiffs, however, have agreed with the state regarding provisions of the consent decree itself, but have objected to some of the attached notices and the time frames that the Defendants have requested to implement some of the other changes.

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