Binta B. v. Gordon (formerly Grier v. Goetz)
- 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. The HMO never explains to you why the coverage is being denied.
- 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 and Grier v. Goetz, 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 on TennCare’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 teens who are in a youth development center and for enrollees who successfully appeal a denial of services.
In 2005, the State sought to have the protections of the settlement agreement stripped from the entire TennCare population. After a three-week trial in which TJC represented the interests of all TennCare enrollees, the Court granted the State some of the changes it sought, but refused to grant it others. See orders from August 3, 2005, August 9, 2005, and November 15, 2005 (Part 1 and Part 2). The current order, which explains TennCare enrollees’ rights when their HMO denies the care their doctor orders, is available here.
TJC continues to monitor and ensure the State’s compliance with the Binta B. consent decree through both individual and systemic work.
Children in State Custody
Binta B. offers special protections for children in state custody. You can learn about those special protections by reading the following orders:
- Agreed Order Governing TennCare Appeals for Children in State Custody (“Detailed Plan”). (January 14, 2000)
- Agreed Order. (July 13, 2004)
- Revised Consent Decree, Modified (“Amended RCDM”). (Special provisions relating to children in state custody are located in section C.15.) (February 5, 2008)