One of the issues that we see facing many of our clients is an inability to implement and access services once an application for Community Medicaid has been filed and approved. Oftentimes the reason for this is that they are unaware that there is a secondary process which much be followed to access the services, moreover for those clients who have been receiving services they often face a reduction of hours and are unaware that they can appeal that decision.
After an individual is financially approved by the local Department of Social Services for Community Medicaid, he or she must enroll with a Managed Long-Term Care Company (or “MLTC”) in order to access services. The MLTC will send a nurse to the Medicaid recipient in order to evaluate and create a care plan. The evaluation typically will result in an award of hours to the Medicaid recipient for a home health to come to the home and assist the recipient with activities of daily living. The amount of hours can consist of a few hours per day or live-in care depending on the needs of the Medicaid recipient.
Once enrolled, the recipient may request an increase in hours based on a decline in health and additional assistance required. There is a possibility, that upon a re-assessment, the MLTC could determine that the recipient has improved and make the determination to decrease the original awarded hours. If the MLTC plan seeks to deny an increase or reduce personal care services, the recipient can file an appeal. Effective May 1, 2018, the recipient must first request an internal plan appeal and wait for a decision prior to filing a hearing with the Office of Administrative Hearings. Additionally, in order to file an internal appeal on behalf of a recipient, the representative must have authority in writing on file with the MLTC plan. It is important to have the authority in writing on file with the plan from the time the recipient is enrolled because if there is a decrease in hours, the representative will only have ten (10) days to file the appeal.
This process can be overwhelming and difficult to navigate. If you have questions, you should consult an Elder Law expert in your area.