The Medicaid Maze: Securing Home Care in New York

For many New York families, obtaining adequate Medicaid home care feels like an uphill battle against a complex and often unresponsive system. At Sammartino & Sultan, we understand the frustration and stress this process can cause. Let's shed some light on why securing home care hours can be so challenging and how you can better navigate this system.

The Privatization Predicament

New York's Medicaid home care services operate largely through a privatized model. The state contracts with private managed care plans to administer these services. While intended to improve efficiency, this setup often leaves families struggling to obtain the care they need.

The Profit Motive

Managed care plans receive a flat fee per enrollee, regardless of services provided. This creates a strong financial incentive to minimize approved home care hours. For example, if a plan receives $5,000 per month for each enrollee, they profit more by providing fewer services. This can result in a family needing 40 hours of weekly care only receiving approval for 20 hours.

A Bureaucratic Labyrinth

The complexity doesn't end with managed care plans. Multiple layers of bureaucracy further complicate the process:

State government agencies (e.g., New York State Department of Health)
County-level offices (e.g., local Departments of Social Services)
Managed care organizations

Each entity operates under its own rules and regulations, often leading to:

Conflicting information:
One office might tell you you're eligible for certain services, while another denies them.
Unclear guidance:
Families often receive vague or incomplete instructions on how to proceed.
Communication breakdowns:
Information doesn't always flow smoothly between these different entities.
Delays in care approval:
The back-and-forth between different offices can result in weeks or months of waiting.

Add widespread staffing shortages to this mix, and families often feel lost in a maze of red tape.

Understanding the Assessment Process

A critical part of securing home care hours is the assessment process. Typically, a nurse from the managed care plan will conduct an in-home assessment to determine the level of care needed. However, these assessments can be subjective and may not fully capture the extent of care required.

For instance, an assessor might observe a patient on a "good day" and underestimate their overall needs. Or they might not fully account for nighttime care requirements if the assessment is done during daytime hours.

Your Rights and Advocacy

Understanding this system is the first step toward effective advocacy. Here are some key points to remember:

Know Your Rights: Familiarize yourself with Medicaid regulations and your entitlements. For example, you have the right to appeal any decision about your care.
Document Everything: Keep detailed records of all interactions with Medicaid offices and managed care plans. This includes dates of calls, names of representatives, and summaries of conversations.
Appeal Denials: Don't accept initial rejections as final. The appeals process can often lead to better outcomes. You typically have 60 days from the date of a denial to file an appeal.
Seek Expert Help: Consider consulting with attorneys experienced in Medicaid law. They can navigate the complex regulations and advocate on your behalf.
Prepare for Assessments: Before any in-home assessment, document daily care needs in detail. Consider keeping a care journal for a few weeks to provide a comprehensive picture.

How Sammartino & Sultan Can Help

Navigating Medicaid's complexities shouldn't be a solo journey. Our experienced team at Sammartino & Sultan specializes in helping families secure the home care hours their loved ones need. We understand the system's intricacies and can guide you through:

⇒ Interpreting complex Medicaid regulations

⇒ Preparing strong applications and appeals

⇒ Negotiating with managed care plans

⇒ Advocating for your rights at fair hearings

⇒ Challenging inadequate assessments

We can help you understand the specific criteria used in assessments and ensure that all relevant factors are considered. Our attorneys can also attend assessments with you to ensure your rights are protected and all necessary information is properly documented.

Don't let the system's complexities prevent your loved one from receiving necessary care. With the right knowledge and advocacy, it's possible to secure the home care hours you need.

Contact Sammartino & Sultan today for a consultation. Let us help you navigate the Medicaid maze and ensure your loved one receives the care they deserve. Remember, you're not alone in this journey – we're here to guide you every step of the way. Reach us here.

About the Author

Christina has been practicing law in New York State, for over 7 years. She is a Pace University School of Law graduate. After passing the New York and New Jersey Bar Exams, she went on to work for several law firms with primary practice areas in Real Estate, Estate Planning, Estate Administrations, Guardianship proceedings under Article 81 of the Mental Hygiene Law, and Article 17A, Medicaid planning and applications. Christina is also certified as a Guardian, Court Evaluator, and Attorney for the AIP under Part 36 of the Rules of the Chief Judge.