getting the needed care

Great News: Your loved one has been approved to receive Community-Based Medicaid for home care. But now what?   

You must begin the complicated process of applying for home care in New York. The Medicaid system here provides most long-term home care services through a program called Managed Long-Term Care (MLTC).

New York State Medicaid pays the MLTC plans what amounts to a flat monthly fee, per recipient, to manage the long-term home care services of Medicaid recipients – essentially taking the state out of the equation. Once the MLTC accepts someone on to their plan, they are required to provide all the needed services (which can include home care, adult day care, incontinent supplies, and medical transportation), with an eye towards keeping costs down. As a result, the Medicaid recipient often receives fewer services than what’s actually required.

The MLTC plan can, in part, justify covering fewer services because they look at only task-based needs and apply very specific blocks of time (counted via minutes) to each physical task with which assistance is needed. Based on the total minutes of care needed each day, they offer a block of time to meet those needs.

They are not required to offer any time at all for “supervision-based” tasks or for “safety.” If your loved one is unsteady on her feet and at risk of falling, she is not going to get any time allotted for that need. If she is confused and forgetful, she is not necessarily going to get services to keep her at home. Those types of needs are not going to be captured in their assessment, allowing the MLTC plan to offer fewer hours than needed.

This type of assessment is especially difficult for those with dementia. Their needs are often supervision-based so they rarely get the type of services they require from a MLTC plan. Even when physical care needs are clearly presented, reduced hours are typically offered.

By example, Colleen Smith was presented by her family as unable to transfer (get up by herself). She needs physical assistance to get anywhere, including to the bathroom. Her family was told by the MLTC plan that even though Colleen needs help getting to the bathroom, they cannot have an aid “sitting around all day” waiting for this. So while this is the actual purpose of the home care services, Colleen is left short of the care she needs.

As a result, presenting needs clearly and appropriately is critical when attempting to get the proper amount of care. Even with the best presented case, people often are denied critical services.

If you are denied the hours needed, you can try an assessment from another MLTC plan. I find this is rarely successful. The next step would be to appeal the hours allotted by the MLTC plan. The appeal is an internal process within the plan and almost always results in no changes. This first denial for additional hours is called an Initial Adverse Denial. If your initial appeal is denied, you can present more documentation (doctors’ letters and specific care issues) and appeal again. Most often, this still doesn’t get the needed hours, and you’re issued a Final Adverse Denial.

From there, you can go for a Fair Hearing. The biggest benefit of a Fair Hearing is that it’s heard by a judge in your local county social services office. This would be the first time someone outside the plan is determining if the care plan is appropriate. Often, the hours are granted at this point.

All of this can take months and, during that time, you (your loved one) may not be getting the needed coverage.

Another home care option is the greatly underutilized Nursing Home Transition and Diversion (NHTD) program, which currently falls outside of managed care, but can provide the coverage and time for supervision and safety – unlike the MLTC plans. This is a great alternative for people with dementia, as it offers a lot of supervision and safety-based needs.

Having a specialist guide you through the difficult tasks of either obtaining required care, fighting for more hours, or switching to another program can be essential for the best interests of your loved one.

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