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In July 2016, the NYS Department of Health launched a new procedure that fast-tracks the approval of Medicaid applications for applicants who have an "Immediate Need" for either personal care or Consumer Directed Personal Assistance (CDPAP) services. 16ADM-02 - Immediate Need for Personal Care Services and CDPAP Services (PDF) (Attachment) The State directive implements a law passed in April 2015, which requires local Medicaid offices to process and approve a Medicaid application in SEVEN DAYS, and authorize personal care or CDPAP services in TWELVE DAYS, if there is an immediate need for these services.
The new procedures are explained in this article. The procedures require submitting a new Attestation Form that certifies the applicant's immediate need, along with a "physician's order" for home care, known as the Form M11q in NYC (other counties have their own forms).
The new procedures are significant for several reasons.
First, when managed long term care became mandatory in 2012, the "front door was closed" for accessing home care through the local Medicaid office; the role of local Medicaid offices was now solely to process Medicaid applications. Once approved for Medicaid, a "dual eligible" (someone who has Medicaid and Medicare) needed to obtain a Conflict-Free assessment, then choose and enroll in a Managed Long Term Care plan (regional lists of plans here). When it passed the 2015 law, the State legislature was responding to reports of long delays endured in applying for Medicaid and going through this MLTC enrollment process.
Second, the new law and procedures expedite approval of Medicaid in just SEVEN DAYS, for those who have an immediate need for these home care services. We know that meeting this deadline will pose a challenge for local Medicaid programs and hope that they are given the support they need.
We salute the New York State legislature and Governor Cuomo for enacting this legislation, with the leadership of Assembly Health Committee Chair Richard Gottfried and State Senate Health Committee Chair Kemp Hannon, We further commend the Department of Health for developing these procedures thoughtfully, taking into account input from NYLAG and other consumer advocates. In particular we commend the Dept. of Health for these features of the procedures that we recommended:
- Married applicants may request spousal impoverishment protections for their spouses. Before, this budgeting method could only be requested after the individual enrolled in an MLTC plan, causing needless impoverishment and confusion. See article for how to request this.
- People who are temporarily in the hospital or who are in a nursing home may request expedited Medicaid and/or home care so that they can return home, as shown in the Attestation Form.
- All new applicants for Medicaid are given a fact sheet explaining the new procedures (page1 at this link)
- Applicants are eligible if their voluntary informal caregivers cannot continue to provide needed assistance to the applicant. Earlier drafts of the form had suggested that an applicant whose family is currently providing informal care does not have an "immediate need," even if this informal care cannot continue. Similarly, even if client is receiving Medicare home care services, which are usually very limited, she can qualify because Medicare is not providing "needed assistance" in the amount needed.
Since the procedure is new, be sure to refer to the new ADM when you are applying, and use LawHelpNY to find your local legal services organization if you encounter problems or delays. Or you can contact the ICAN Ombudsprogram regarding delays enrolling into MLTC.
This news item also appears here. Read more about these procedures here.
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Medicaid Matters NY, a statewide coalition, along with the New York Chapter of the National Academy of Elder Law Attorneys, issued a Report called "Mis-Managed Care: Fair Hearing Decisions on Home Care Reductions by MLTC Plans: July - December 2015." The Report, issued in July 2016, can be downloaded here. The report was featured in a story in the New York Times published on July 21, 2016 – Insurance Groups in New York Improperly Cut Home-Care Hours for Disabled Patients, Report Says, Follow up articles were published in Crain's Health Pulse.
The Report identified every fair hearing decision posted in the OTDA Fair Hearing Decision Archive concerning reductions by MLTC plans during the last six months of 2015. The 1,043 decisions reveal a pattern of arbitrary and illegal reductions in hours of home care services. While most members win these hearings, for every member who had the wherewithal to request, travel to, and present their case at a hearing, undoubtedly there were many who could not. The report calls on the State to restore services for these vulnerable New Yorkers, to stop plans from engaging in these illegal reductions, and to improve its oversight of these private plans spending public dollars.
The number of decisions issued each month increased six-fold during the six-month period. In 90% of the 1,043 hearing decisions identified, MLTC plans’ attempts to cut services were thwarted, either by a plan member winning the hearing or because the MLTC plan failed to show up to defend the proposed reduction at the hearing. In a smaller but significant percentage of the decisions, the case was settled through an agreement in which the member -- often without an attorney to advise them -- agreed to accept some reduction in hours that was less than the plan originally proposed. Although most of the hearings identified for the report involved people in New York City, seniors and people with disabilities struggle with arbitrary home care reductions statewide.
Get Help -- Representation is available for people facing reductions in services by MLTC plans. Contact ICAN - the Independent Consumer Advocacy Network - the State ombudsprogram for MLTC, FIDA, and other Medicaid managed care programs providing long term care services. Call (844) 614-8800 TTY Relay Service: 711.
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