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Reduction In Community Medicaid Benefits: Fight Medicaid At Fair Hearing

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 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.

EXAMPLE:

Sally from Smithtown, NY, age 95, has been in receipt of Medicaid benefits provided through a Managed Long Term Care Plan. By notice dated July 20, 2017, the Managed Long Term Care Plan determined to reduce Sally’s Personal Care Services authorization from 84 hours per week (12 hours daily, seven days weekly) to 54 hours per week (8 hours daily, five days and 7 hours, two days). On July 21, 2017, Sally requested a fair hearing.

The Managed Long Term Care Plan’s notice of reduction dated July 20, 2017, was carefully reviewed at the hearing as to the specific reason to justify its action to reduce Sally’s Personal Care Services authorization, such as a change in Sally’s medical, mental, or social circumstances, or if a mistake occurred in the previous personal care services authorization, etc.

The notice provided, in part, as follows:
We made a mistake assigning more personal care hours needed to perform personal care aide tasks. According to a nurse’s assessment, you require only limited assistance, walking, locomotion, bed mobility and eating. You are ambulatory with the rolling walker indoors and have a personal emergency response system you can use effectively. Based on this review of your care needs and your ability to assist in those needs, current services can be reduced to 8 hours daily five days (M-F) and 7 hours two days a week for a total 54 hours.

DECISION: Sally wins.

The evidence established that the Managed Long Term Care Plan’s notice dated July 20, 2017, did not adequately identify an appropriate reason and no material error was indicated to justify its action to reduce Sally’s Personal Care Services authorization. Therefore, the reduction in benefits is reversed.

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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