A primary focus of our practice is helping clients access Medicaid to pay for home health aides. We call this Medicaid Home Care. Since Medicaid is a means-tested program, we begin with ensuring the client is eligible financially, both income- and asset-wise. See https://tinyurl.com/qqhcy7l . That can be a complex process, depending on each individual client’s circumstances. Once eligibility is established, we can file a Medicaid application. Depending on how urgent the client’s need is, we determine whether to file the application in the ordinary fashion or in an expedited manner. Regardless of which route we use to get the Medicaid in place, however, the process that follows – that of actually getting the care in place – is equally as complex and fraught with opportunities for delay.
This is where care coordination and care management come in.
Over the several years since the New York State Medicaid program switched over to the managed care model of delivering home care, the Managed Long Term Care (MLTC) agencies that provide the services (and the state) have consistently become less and less generous with the number of hours of care they are willing to give to individuals. More and more, we see people with very extensive needs getting so few hours that they cannot live at home safely. Some of these actions are by design. The MLTCs are paid on a capitation of benefits basis, which means they receive a fixed amount per person per month instead of being paid on a fee-for-service basis. Thus, their incentive is to give as few hours as possible. This is because they receive the same amount of money from Medicaid if they give Mr. Smith 4 hours per day as they do if they give him 24 hours per day. See the problem?
Notwithstanding the fiscal strain the MLTCs and the state are under, this is actually in violation of the laws governing Medicaid. However, in order to force the state and the MLTCs to comply with the law, it is necessary to appeal their decisions much more frequently than in the past. The bottom line from a client advocacy and elder law standpoint is that we have to work much harder to get our clients the amount of care they need and deserve. This has given way to the inclusion of much more care coordination into many elder law practices, such as ours.
Although we’ve always been hands-on where the care is concerned, we have recently begun having a care manager go out and do a preliminary assessment of the client’s needs and provide us with a report. The care manager will then arrange and attend the initial required state evaluation, as well as the subsequent evaluation by the MLTC. This does a couple things. It allows us to counsel the client and the family and advocate for proper hours right up front – before the MLTC determines the hours they will offer. It also makes it easier for us to appeal if the hours given are unsatisfactory. Additionally, it provides the family with someone who understands the Medicaid “language” and can prevent the family from getting stuck in a cycle of confusion that can ensue once they start getting conflicting or unsatisfactory information from the evaluators.
For families who need or want more hands-on assistance, we can also provide additional care coordination services and assistance with getting their finances in order. As always with Medicaid and government benefits in general, when circumstances change, we have to make changes accordingly, in order to provide the best service and advocacy for our clients.