Demanding Ascertainable Standards: Medicaid as a Case Study

Executive Summary

State Medicaid agencies and their contractors are increasingly relying on preset guidelines or assessment tools or both to make coverage decisions. Problems arise when the use of these tools results in program enrollees and advocates being refused access to the standards and procedures that govern the operation of the program. Such practices prevent the use of “ascertainable standards” and are inconsistent with the use of public funds, and create serious Medicaid and due process problems. This article describes the legal protections that should prevent the application of secret standards in Medicaid, as well as other public benefits contexts.