Question: My father was recently enrolled into a Managed Long Term Care Company. I am having a hard time navigating his benefits and getting the care at home that he needs. Are there any options?
Answer: Yes, there are options. First, a basic understanding of the Managed Long Term Care Program (“MLTC”) is helpful when trying to navigate the benefits. When someone is approved for Community Medicaid benefits, they are required to enroll in a MLTC. The MLTC is responsible for managing all of the home care benefits for the individual. This would include (but is not limited to) home health aides, day care programs, supplies, transportation to and from doctor appointments and some durable medical equipment. In order for the MLTC to cover a specific service, it must be “medically necessary”. Working with your MLTC care manager and primary doctor is crucial in order to maximize the benefits under the program.
But what happens when the MLTC denies a request or is not providing enough support? One area that we see in our practice that people struggle with is getting enough home care hours covered by the MLTC. The MLTC will determine how many hours per day and number of days per week an individual is eligible for under the program. The award of hours is based upon activities of daily living (i.e. bathing, feeding, ambulating, toileting). For example, the MLTC may award 6 hours per day, 5 days per week – which means that a home health aide would come to the house for those hours and be covered by Medicaid. There are situations where the MLTC does not agree with the family members as to how many hours and number of days per week the member should receive. In this case, an appeal may be necessary.
When more hours are needed but not approved, the enrollee or agent representative of the enrollee, can request an internal appeal. This would require the MLTC to reevaluate the care plan and potentially approve a higher level of care. The typical appeal process can take up to 30 days unless a “fast track” appeal is request and then a decision must be rendered within 72 hours. If the requested relief is not approved, a Fair Hearing can be sought. In the Fair Hearing, the MLTC puts forth an argument as to why the current care plan is appropriate and the enrollee (or representative) puts forth an argument as to why more care is needed. The Fair Hearing is decided by an Administrative Law Judge. If the enrollee is successful in presenting his or her case, the MLTC will be required to approve the higher level of care.
Navigating the MLTC process and maximizing the covered care can be difficult. If successful, you may be able to keep your loved at home with the proper support. Consulting with an expert in your area may assist you in getting the appropriate benefits in place.