If the answer is yes, you are in good company. In the New York City boroughs, we have traditionally been able to obtain the needed amount of home care through the Medicaid program for our clients in order to enable them to live safely in their homes. Since the Managed Long Term Care (MLTC) system was implemented in 2012, the MLTCs are the primary agencies responsible for providing the care. They have contracts with Medicaid, whereby Medicaid pays them a per-head monthly price for each person on their rolls. This is a “capitation of benefits” model, as distinguished from a fee-for-service model, which is the way care was traditionally paid for. In other words, the MLTC receives the same amount of money per month for someone needing 2 hours/day as for someone needing 24 hours/day. The MLTCs then contract with home care agencies to provide the home health aides to the consumers. If you think this paradigm encourages the MLTCs to provide as few hours per day as possible, you would be right.
Since the adoption of this system, MLTC plans have been getting overwhelmed financially and several have pulled out of the marketplace. We started with 25 MLTCs and we now have only 18. Then to make a difficult situation worse, effective March 1, 2020, the MLTCs will no longer be responsible to keep a patient on their rolls once that patient goes into a nursing home. The unfortunate, yet predictable, effect of this change is that the MLTCs are now starting to deny care to high-need cases, using the pretext that they need too much care and must go to a nursing home and thus off their rolls – or saying that they need too little care and offering them 6 hours/day. The results have so far been devastating. See my previous blog post with an article in the news on February 27, 2020, about two (2) women who could not get enough care from The Centers Plan, who wandered from their homes and were found dead. These were two separate cases – one in Bronx and one in Brooklyn.
In my own office, I’m presently working on several cases in which the seniors need 24-hour care and they are being offered 6 hours/day or being denied altogether. This is contrary to the law and the Medicaid and MLTC regulations. They are doing it anyway. They explain their decisions to the clients as if that’s just the way it is. The clients do not know any better. Why would they? This is dishonest and legally incorrect.
It is important to be aware that consumers have the right to appeal these incorrect decisions. If the award of hours is inadequate, start by asking them to review and reconsider. If they will not reconsider, you might want to accept their offer and request a re-evaluation for additional hours the moment the care begins. If they deny an increase (which they must do in writing by issuing an Initial Adverse Decision), then you can do an appeal. You must begin by doing an internal appeal to the plan. If you get an Initial Adverse Decision, you can appeal that decision. If the plan denies the appeal and you get a Final Adverse Decision, you can either do an external appeal to an intermediary or request a Fair Hearing through the Office of Temporary Disability Assistance. If you are inclined to hire an attorney to handle this process for you, I would recommend doing so at the beginning of the process rather than waiting until the end. We sometimes have better results applying the pressure directly to the plans, as opposed getting involved at the end of the case.
Since this is a widespread problem, we try to intervene as early as possible. If our office has handled applying for the home care in the first place, we will have our own assessment of the care needs done before the MLTC comes out to do their initial assessment. That accomplishes two things: it allows us to advocate at the plan assessment in real time, and it sets us up with material for the appeal if we get insufficient hours. If we haven’t been involved from the beginning but the family contacts us to handle the appeal, we will also go out to the home and do our own assessment so we’re armed with the information needed to refute the methodology or the conclusions of the MLTC.
Families need to be aware of their rights. It is very hard to deal with these agencies because they are laden with bureaucratic “red tape”, and you can ask the same question to four different people and get four different answers. They do not document their files correctly when consumers call. They transfer the call many times, sometimes back and forth to the same departments. The proverbial right hand doesn’t know what the left hand is doing. It is hard to know how much of this is intentional in order to cause delay and how much is simple incompetence or inadequate staffing or training. Regardless of the cause, it is important that consumers understand that they have the right to appeal and/or to retain counsel to assist them.