In the MLTC program, however, the Department of Health authorized MLTC plans to reduce and terminate hours of home care services, with no right to Aid Continuing, if the plan’s service reduction coincides with the end of the plan’s “authorization period” for the services. Home care services have always been authorized for an "authorization period" of up to six months. This ensures that the administrator - whether the local Medicaid program or an MLTC plan -- has reassessed the individual's needs to make sure services meet changing needs. Since these are LONG-TERM care services, the end of the authorization period does not mean services should end - they should be reauthorized with no interruption. But - the State's view allowed disruption and even termination of these services without these crucial hearing rights.
The NYS Budget incorporates an Assembly Bill proposed by Chairman Gottfried (A4996) that guarantees the right to receive AID CONTINUING "without regard to expiration of a prior service authorization." The final budget bill is A9205 Sec. 42, amending Soc. Services Law Sec 365-a, subd. 8 (Section 42 is at pp. 134-135 at this link). See NYLAG Statement in Support of A4996.
WARNING: MLTC members must still "exhaust" their internal appeals within the MLTC plan before they request a fair hearing. Many people don't realize that their fair hearing will be DISMISSED if they did not first request an INTERNAL APPEAL from the MLTC plan. See more about MLTC appeals in this article.
It is hard to overstate the harm caused by denying “aid continuing” for dual eligibles receiving long term care services. An individual whose 24-hour care is reduced to 8 hours/day would be at severe risk of harm if left alone 16 hours/day without care for several months, while a fair hearing is pending to challenge the reduction. Falls and other accidents, malnutrition, pressure sores could result. Without help to take medications, medical conditions could deteriorate. The result could lead to avoidable hospital stays, institutionalization and even death. It is the prevention of this irreparable harm that is the cornerstone of due process.
Here's an example of one of NYLAG's clients who will now be protected by this change:
Recent Example of Illegal Denial of Aid Continuing
In November 2013, a managed long term care plan threatened to reduce 24-hour split-shift continuous home care to 12 hours a day for Ms. D, a severely disabled New York City resident who cannot get out of bed or go to the bathroom without an aide’s help. Though she requested a hearing, the managed care plan and the State’s hearing office contended that she did not have the right to “aid continuing” for the months that the hearing would take, because the date of the threatened reduction coincided with the last day of the so-called “authorization period” of the services. She would have been left alone 12 hours per night had not NYLAG been able to reach a settlement in her case. Thanks to this new change in the law, it won't happen to her when the next authorization period ends -- or to thousands of others like her.
Authorizes language to create a Basic Health Program
Expansion of the membership and scope of the Medicaid Managed Care Advisory Review Panel (MMCARP), including new language proposed by Assembly Health Chair Gottfried to require review of notices, trends in service denials, and more. It also requires MMCARP meetings to be webcast.
Limiting recovery against Estates of MAGI recipients - When many people across the nation expressed reluctance to apply for the expanded Medicaid on the Exchange, for fear of a lien being placed against their Estates after they die, CMS issued a policy directive in February 2014 that allowed States to limit the scope of recovery. Though this came late in the NYS Budget process, CSS Community Health Advocates, NYLAG and other advocates succeeded in convincing NYS to exercise this option afforded by CMS. For anyone who obtains Medicaid using the new "MAGI" budgeting, a lien on their Estate can only be placed if they were over age 55 when they received Medicaid, and only for the cost of certain services -- nursing home services, home and community-based services, and related hospital and prescription drug services. MAGI recipients are generally not eligible for nursing home care anyway. This is section 62-a of the budget law at A9205/6914. NOTE that this does not apply to "non-MAGI" recipients - anyone who has Medicare is non-MAGI and is still subject to a lien against their Estate for the cost of all Medicaid services received after age 55.
EPIC INCOME LIMITS RAISED - This is the state-funded prescription drug subsidy program for people age 65+ to subsidize costs incurred with Medicare Part D. Effective April 1, 2014, the income limit for the deductible plan will increase from $35,000 to $75,000/year for those who are single and from $50,000 to $100,000/year for those who are married. See EPIC's website for old rules. In the new eligibilty group:
SINGLE deductible will go up to $2,430 year for highest income (up from max of $1,230/year)
MARRIED deductible will go up to $3,215/year for highest income (up from max of $1,715/year)
See Sections 12-13 of A9205/6914 (pp. 19-21)
¹DUALS COALITION STEERING COMMITTEE: Center for Disability Rights ● Center for Independence of the Disabled/NY ● Community Services Society ● Consumer Directed Personal Assistance Association of New York State ● Empire Justice Center ● Legal Aid Society NYC ● Medicare Rights Center ● New York Association on Independent Living ● New York Legal Assistance Group.