The frail elderly are the fastest growing segment of the U.S. population. According to one census report, the over 80 segment is growing at almost four times that of the total population. New York City’s elderly population is increasing at this same intense pace. This tremendous growth is resulting in a greater need for long-term care services, particularly for Medicaid home care.
Unfortunately this increased demand is being countered by today’s political climate that is attempting to limit Medicaid services. State, city and federal governments are pressuring certified Medicaid agencies to reduce spending by reducing service. New York State is no exception. Agencies are encouraged to limit hours and deny requests for increased care.
This hostile environment is making it difficult for the frailest elderly to get around the clock home care. Fortunately getting this amount of care is not impossible. The key is to understand what factors must be considered. Here are four key factors:
- “No” Does Not Always Mean No!
When a home care agency assesses a client for care it must provide you with its decision in writing. Each report must indicate reasons for their denial and include a statement on the two ways you can appeal the decision.
The first choice is to request an internal appeal. You can take your case to the agency’s management and state why you disagree with their reasoning. At this time you can offer evidence on why more care is needed.
The second choice is to request a fair hearing. This is a chance to bring your case before a law judge at the New York State Office of Temporary and Disability Assistance, Office of Administrative Hearings. The judge will hear the evidence that both you and the agency provide and make a decision.
- Know the Requirements of Around the Clock Care.
The number of hours of home care a client receives is determined by three factors: the number of Activities of Daily Living (ADLs) a patient requires, the frequency of that care, and if the care needs are predictable and can be scheduled.
The six ADLs that are evaluated are eating, bathing, dressing, toileting, transferring (walking), and continence. Once the agency determines the needs, it determines how often the needs must to be addressed. Finally it determines if these needs can be scheduled at regular intervals during the day with only occasional disruptions at night. If your mother needs to be toileted during the day, but rarely needs assistance at night, the agency can deny your mom around the clock care. However if your mom requires so much assistance at night that her attendant cannot sleep, she is eligible to get split shifts, an aide who will watch her during the day and one to watch her at night.
- Review the Agency’s Assessment Report.
As noted above, a client must receive a copy of the nurse’s assessment that indicates the amount of care required. Look through the report, noting any inaccuracies. If the assessment states that Mom can walk 50 feet unassisted and you know she can barely stand by herself, the assessment is questionable. Some agencies actually use information from outdated reports that might not reflect your mother’s current situation. Make sure to point out these inaccuracies when you appeal your case.
- Offer Concrete Evidence of Need.
Nothing is more important than actual facts. Medicaid is not interested in your concerns for your mother’s safety; they want concrete evidence that she is unsafe without that care.
The best way to substantiate information is to document how often and when your mother needs nightly assistance. You might have to spend a couple of nights with her to get concrete evidence. You should record how often your mom gets out of bed at night, how unsteady she is, and the number of times she almost falls. Record each incident including dates and times. You should also approach your mother’s doctor to get records of previous visits and get a recommendation from him.
The best way for winning a case for around-the-clock care is by providing evidence. Many families spend time expressing their concerns without offering proof. These statements express wants not needs. The only method that convinces a judge of a need is by providing factual information. In this tight political climate a family who can express its needs and not its wants is more likely be a winner.
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