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Community Medicaid, Disturbing Trend In Smithtown: Reduction In Benefits

When an individual needs help with the activities of daily living, to avoid a nursing home and remain in their residence, a benefit worth obtaining is Community-based Medicaid. Community Medicaid will pay an agency that will provide home health aides to assist with Personal Care Services in the home.

Unfortunately, we are seeing a disturbing trend throughout Suffolk and Nassau Counties where clients have been approved by Medicaid, granted Personal Care Services, obtained and received Personal Care Services, and are now being told that their benefits are being reduced. These reductions are often by hours per day and by days per week; aides are becoming less and less available to individuals. Managed Long Term Care Plans are making determinations to reduce Personal Care Services authorizations.

If Medicaid or Managed Care Organizations are terminating or reducing benefits, a notice must be sent that states the reasons for reduction, discontinuation or denial of a reauthorization for Personal Care Services. Appropriate reasons for reducing, discontinuing or denying a reauthorization of Personal Care Services include but are not limited to:

1. the individuals’ medical, mental, economic or social circumstances have changed and the Managed Care Organization determines that the Personal Care Services provided under the last authorization or reauthorization are no longer appropriate or can be provided in fewer hours than they were previously;

2. a mistake occurred in the previous Personal Care Services authorization;

3. the individual refused to cooperate with the required assessment of services;

4. a technological development renders certain services unnecessary or less time-consuming;

5. the individual can be more appropriately and cost-effectively served through other Medicaid programs and services;

6. the individual’s health and safety cannot be reasonably assured with the provision of Personal Care Services;

7. the individual’s medical condition is not stable;

8. the individual is not self-directing and has no one to assume those responsibilities;

9. the services the individual needs exceed the personal care aide’s scope of practice.

Aaron E. Futterman, CPA, Esq. is a partner in the law firm of Futterman & Lanza, LLP with offices in Smithtown, NY and Valley Stream, NY and clients throughout Suffolk, Nassau, Queens, Brooklyn, Bronx, Richmond, New York, Westchester and Rockland Counties. He concentrates his practice to Elder Law, Medicaid Planning, Medicaid Applications, Estate Planning, Probate, Estate Taxes, and Estate Administration.

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