Introduction
Certified Medicaid Planners (CMPs) can help seniors maximize the long-term home care benefits they receive from Medicaid. To start, CMPs carefully examine their client’s medical history, communicate with their healthcare providers and assess their current condition and living situation. This comprehensive evaluation will determine what home care benefits the senior should apply for, as well as what documents and testimony should be submitted with the application to ensure those benefits are granted. If they are not granted, CMPs can then guide their clients through the appeal process. This usually begins with informal communication with the local Medicaid agency to request a change in the benefits decision, and then escalates to filing a formal appeal for a fair hearing, if necessary, and representing the client at that hearing to ensure they receive the home care benefits they need and deserve. The added benefits might include increased hours of personal care, more in-home nursing visits or the addition of enhanced supervision for individuals with dementia.

Pre-Application Assessments and Preparation

Much of the work for maximizing benefits takes place before the Medicaid application is submitted. It begins with the initial consultation as the CMP starts to understand the senior’s medical needs, their residential environment and the care they are already receiving. This includes their ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) with and without assistance, the safety and accessibility of their home, and any care from family or friends. CMPs will also communicate with relatives and close friends to get a more complete picture of the situation from people who have known the client on a personal level for an extended period time.

Then, CMPs will assess their client’s situation from the professional point of view, which is critical when it comes to maximizing home care benefits. This often begins with a careful examination of all the client’s medical records, which includes reviewing diagnoses, medications, procedures, hospitalizations, in-home safety measures and durable medical equipment usage. Next, the CMP will communicate with the individual’s full team of healthcare providers to ensure a collaborative and streamlined approach. Finally, if they think it’s necessary to establish care needs in order to maximize benefits, a CMP will help schedule further medical or psychological evaluations.

At Eldercare Resource Planning, we team with the evaluation experts at Callahan Care Solutions to offer our clients Level of Care Assessments that align with the medical evaluations used by Medicaid officials in their state. These assessments include the type of comprehensive review of medical history and records, and thorough communication with healthcare providers, described above, as well as any necessary cognitive or functional assessments. The information gathered during our Level of Care Assessments is compiled in detail in documents that can be submitted along with the Medicaid application to help ensure our client’s home care benefits are maximized without any denials or delays.

Home Care Benefits Decisions

Applicants will learn what their exact home care benefits are when they receive the notice of determination that informs them that they’ve been accepted by Medicaid. This will include the types of home care benefits they will receive, as well as the number of hours per week or month they will receive them. The notice of determination will also tell the applicant how to request a fair hearing to appeal the benefits decision, and what the deadlines are for doing so.

Medicaid provides home care benefits through its Home and Community Based Services (HCBS) Waivers or Aged, Blind and Disabled (ABD) Medicaid, also known as state or regular Medicaid for seniors. These programs have different names in different states, and many states have several programs that provide home care. For example, California Medicaid (known as Medi-Cal) will cover home care through its In-Home Supportive Services (IHSS) program, Personal Care Services Program, Community First Choice Option, Multipurpose Seniors Services Program and its Home and Community-Based Alternatives Waiver. Massachusetts Medicaid, known as MassHealth, covers home care with its Frail Elder Home & Community Based Services Waiver (FEW), Personal Care Attendant (PAC) Program and with the Program of All-Inclusive Care for the Elderly (PACE).

Maximizing Benefits for Existing Medicaid Recipients

Applicants aren’t the only individuals who might need the help of a CMP to appeal their home care benefits package. Existing Medicaid recipients could have their home care benefits reduced as part of their Medicaid Renewals process.

States conduct Renewals on an annual basis to ensure Medicaid recipients are still financially and medically eligible, and during the state assessment it might be determined that a recipient should have their benefits scaled back. If this happens, the state will send a written notice to the recipient informing them of the change in benefits. This notice should also include a reason why the benefits are being reduced, the date they will be reduced and instructions for requesting a fair hearing to appeal the decision.

Reasons to Appeal a Benefits Decision

The need to appeal typically arises when there is a discrepancy between a state’s assessment of a Medicaid applicant (or recipient), and the reality of the individual’s daily life and health care needs. The specific reasons to appeal might include:

• Insufficient hours – The state offered some hours of home care, but failed to account for the total amount of care the individual needs with their Activities of Daily Living, their Instrumental Activities of Daily Living (laundry, cleaning, shopping, cooking, etc.), their medication management or any other aspect of their home care plan.
• Denial of protective supervision – The state did not offer sufficient monitoring even though the individual has cognitive issues, such as Alzheimer’s disease or another form of dementia, that call for this type of care. This is a common reason for an appeal.
• Reduction in existing hours – The state decided to reduce benefits during a Medicaid recipient’s annual Renewal because their condition or circumstances have improved, even though there is evidence to the contrary.

Applicants who are denied due to eligibility issues can also appeal. Read more about that process.

Informal Appeals

In some instances, informal communication with the local Medicaid office can result in a second care needs assessment, or even a change in benefits. CMPs are especially helpful in these situations because they know who to contact at the Medicaid office and what to say to have the best chance of a new assessment or a change in benefits. This communication can be via phone, email or in-person, but whatever form it takes, this informal appeal should not delay or prevent one from filing a formal appeal before the deadline. The informal communication might not lead to any changes, and if the deadline for the formal appeal passes while one is waiting to hear back from local Medicaid office, there will be no chance of changing the benefits decision or getting a new assessment.

Requesting and Preparing for a Fair Hearing

Instructions for requesting a fair hearing to appeal the state’s benefits decision will be included with the Medicaid notice of determination, and in the Medicaid Renewal notice following an annual Renewal. For the appeal to be successful, it’s important to follow the instructions provided and meet all relevant deadlines. In some states, Medicaid recipients who file their appeal prior to the date of the proposed change following their annual Renewal will keep their current benefits until a final decision is made on their appeal, so recipients in this situation are advised to file their appeal before the date of the change. This is sometimes known as securing “aid paid pending.”

Appealing individuals and their representatives (family or professional) should closely review the local Medicaid office’s benefits decision. They should look for any flaws or mistakes in the decision, and they should carefully review the reasons for that decision in order to prepare evidence to counter, such as:

• Professional statements – A letter from a licensed medical professional, such as the applicant’s physician, is often the most influential piece of evidence presented at a Medicaid hearing. The professional can detail exactly why the applicant or beneficiary needs certain benefits or requires help with certain Activities of Daily Living. For example, instead of simply stating the applicant “needs help bathing,” a letter from a professional can explain that “due to severe osteoarthritis and balance issues, the patient requires total physical assisted to enter the tub and perform washing tasks to prevent falls.”

• Care logs and task checklists – The individual’s caregiver(s) should keep a detailed log or checklist for at least one week prior to the hearing. The caregiver(s) should document every instance where they provide assistance, what the assistance entailed and how long it took to provide. These logs can be compared directly with the assessment from the local Medicaid office.

• Third-party witnesses – This would include letters or testimony from family members, friends and previous caregivers who can provide “real-word” context and examples of the applicant’s needs that the state evaluator might have missed during their brief assessment.

What to Expect at a Fair Hearing

Medicaid fair hearings are usually conducted over the phone or via teleconference. They are an administrative hearing, which means it is less formal than criminal court, and it is presided over by an Administrative Law Judge (ALJ). The hearing will start with the local Medicaid office presenting their case. Next, the appealing individual or their representative will present their professional statements, care logs, witness testimony and any other evidence they may have, and they have the right to cross examine the individual who did the care needs assessment (usually a social worker).

Having a CMP as a representative at one of these hearings can be extremely helpful. They understand how the process works and will be ready for any potential roadblocks. They know what type of evidence is needed to get a ruling in their favor, the best way to present that evidence, and all the other best practices needed to ensure their client’s home care benefits are maximized.