Ekloff v. Rodgers

The Consent Decree in the Ekloff vs. Rodgers litigation regarding incontinence briefs (diapers) was signed in November 2006. This settlement provides for coverage of incontinence briefs (diapers) to class members as described below:

Coverage: Incontinence briefs (diapers), including pull-ups, are covered for AHCCCS members who have a documented disability, in order to prevent skin breakdown, and to enable participation in social, community, therapeutic, and educational activities. Coverage shall be determined by:

1. Documentation of a disability that causes incontinence of bowel and/or bladder; and
2. A prescription from the PCP or attending physician ordering the incontinence briefs (diapers).

Age Limit: Coverage for incontinence briefs (diapers) is limited to members over age three (3) and under age twenty-one (21).

Number of Briefs (diapers) per Month: The benefit is limited to 240 briefs (diapers) per month, except in cases involving members who are diagnosed with chronic diarrhea and/or spastic bladder. In these cases, more than 240 briefs (diapers) shall be authorized when evidence of medical necessity is provided by the prescribing physician.

Prior Authorization: Prior authorization will be permitted to ascertain that:

1. the member is over age three (3) and under age twenty-one (21);
2. the member has a disability that causes incontinence of bladder and/or bowel; 
3. a physician has prescribed incontinence briefs (diapers) as medically necessary; and 
4. the prescription is for 240 briefs (diapers) or fewer per month, unless evidence of medical necessity for over 240 briefs (diapers) is provided.
5. a physician prescription supporting medical necessity may be required for specialty briefs (for instance, hypo-allergenic briefs (diapers)) or for briefs different from the standard briefs supplied by the health plan.

Number of Prior Authorizations Per Year: AHCCCS health plans may require a new prior authorization to be issued every twelve (12) months. Prior authorization for a renewal of an existing prescription may be provided by the physician through telephone contact with the member, rather than an in-person physician visit. 

Obtaining Supplies: Members will be required to obtain incontinence briefs (diapers) from the in-network providers contracted with the health plans. AHCCCS health plans and in-network providers will be required by contract to provide standard adequate types of briefs (diapers), including pull-ups.

Dispute Resolution: Any disputes regarding prior authorization will be addressed through the existing administrative appeal system (A.A.C. R9-34-101 et seq.) If an AHCCCS health plan denies a request for prior authorization , the health plan shall provide a notice in writing outlining (1) the specific reason for the denial, citing to the particular prior authorization criteria, in paragraph four above, that it believes are not met, and (2) the citation to the relevant policy or regulation supporting the denial.

Reimbursement for the purchase of incontinence briefs (diapers): Members whose prescriptions for incontinence briefs (diapers) were denied will be reimbursed for out-of-pocket expenses for the purchase of incontinence briefs (diapers) from June 25, 2005 through September 22, 2006. The reimbursement notice explains to members how they can receive reimbursement.  

Cover Letter and Reimbursement Information, [PDF, 24.75Kb]

Provider Notice: Providers are to be notified of the settlement through the AHCCCS website and through Claims Clues.

Policy and Rule Revisions: All AHCCCS policies and rules shall be modified to conform with the Settlement Agreement.

Consent Decree [PDF, 41.20Kb]

Settlement Agreement [PDF, 194.85Kb]

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