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Receiving 24 Hour Medicaid Home Care: Challenges and Solutions

The common notion of requiring “twenty-four hour care” often prompts individuals to seek continuous home care. However, obtaining such care through Medicaid in New York has become increasingly complex. In this discussion, we delve into the various pathways to access twenty-four hour Medicaid home care, potential providers, the enrollment process, and options in case of non-approval. The journey for family caregivers seeking financial assistance for the care of elderly or disabled loved ones can be intricate. We hope this article serves as a useful guide.

  • Two Approaches to 24 Hour Home Care: Split Shift vs. Live-In Care

    There are two main routes to accessing twenty-four hour home care: split shift and live-in care.

    “Split shift” involves receiving two twelve-hour shifts of home attendants daily to ensure round-the-clock availability of care.

    “Live-In” entails a single home attendant staying with the patient for twenty-four hours, necessitating suitable sleeping arrangements for the attendant. Live-in attendants do not receive an hourly rate for the full 24 hours; instead, they receive a daily rate roughly equivalent to about 13 hours of work (hourly billed). This is justified by the expectation that the attendant is not continuously working.

  • Can Medicaid Cover 24 Hour Home Care?

    Since the alterations to the NY Medicaid system in 2011, it has become notably challenging for new Medicaid home care beneficiaries to obtain approval for split shift care. A primary factor is the cost associated with such care. Under the revised Medicaid structure, providers receive episodic or capitation rates, without additional reimbursement for increased services. As split-shift care incurs substantial costs, providers face potential losses. While live-in care approval is also a hurdle, it’s often available for individuals in genuine need.

  • Potential Providers of 24 Hour Medicaid Home Care

    Two key types of mainstream providers that approve home attendant hours are Certified Home Health Agencies (CHHAs) and Managed Long-Term Care (MLTC) plans. Those availing Medicaid services from a CHHA generally aren’t approved for more than 8 hours a day, frequently even less. Conversely, some MLTC plans offer 24 hour live-in care for genuine cases.

    However, even if 24 hour care isn’t attainable through a CHHA, it could still be beneficial to pursue CHHA services while working towards MLTC enrollment. CHHA services are often implemented more rapidly than MLTC enrollment. These services can serve as an interim solution while seeking 24 hour care from an MLTC plan.

  • Securing 24 Hour Medicaid Home Care

    The initial step involves identifying a provider willing to offer necessary 24 hour care. While 24 hour home care is usually sanctioned by MLTC plans, approval rates can differ among them. Seeking advice from individuals experienced in assisting with home care through MLTC is advantageous. They can direct you to an MLTC plan with higher approval odds.

    Once the preferred MLTC plan is chosen, substantiate your request. While many desire 24 hour home care, demonstrate the patient’s genuine “need” for it during assessments by CFEEC and the enrolling MLTC. Provide instances highlighting the patient’s inability to be left alone at any time, such as wandering or falling when awake at night. A letter from the patient’s doctor supporting the necessity for 24 hour care can be advantageous. Align the patient’s actual requirements with the 24 hour care request.

    Bear in mind that patients often resist admitting their need for home care, impacting assessment outcomes. Holding a candid conversation with the patient before the assessment or privately informing the nurse beforehand can help ensure accurate assessment.

  • Non-Approval for 24 Hour Medicaid Home Care

    Receiving a nurse assessment from a MLTC plan doesn’t obligate you to enroll with them. If unsatisfied with the services offered, you can decline enrollment and request assessment from a different MLTC plan. Note that monthly enrollments may mean waiting a month for enrollment if a cutoff is missed. Enrolling initially with an MLTC and then switching to one approving 24 hour care can be an approach. Refer to “Making Changes in Managed Long-Term Care” for potential limitations on plan switching post-enrollment.

    If entirely denied 24 hour care, alternatives exist. Live-in home care is often billed at a daily rate equivalent to around 13 hours of home care. You could potentially negotiate with the licensed home care services agency (LHCSA) providing the attendant to arrange for 24 hour care by paying a supplemental amount. For instance, someone approved for 12 hours a day of home care from their MLTC can contract with their LHCSA to provide 24 hour care for a cost roughly equivalent to 1 hour of daily home care.

    Please Note: This article covers fundamental, practical knowledge essential for savvy consumers pursuing 24 hour home care. Advanced techniques like filing appeals and requesting fair hearings aren’t addressed

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