Community Medicaid In Hauppauge, NY: Medicaid Notice Challenged At Fair Hearing

When an individual needs help with the activities of daily living, to avoid a nursing home and remain in their residence (whether in Hauppauge, Commack, Kings Park, Smithtown, St. James, or any other Long Island town), a benefit worth obtaining is Community-based Medicaid. Community Medicaid will pay an agency that will provide home health aides to assist with Personal Care Services in the home. However, agencies providing Personal Care Services, in a cost-cutting attempt, often attempt to reduce client's benefits provided by reducing the amount of hours of care provided.

A recipient of Public Assistance, Medical Assistance or Services has a right to a timely and adequate notice when an agency proposes to discontinue, suspend, reduce or change the manner of payment of such benefits.

EXAMPLE:

Facts:

Harry from Hauppauge, NY, age 81, is in receipt of Community-based Medicaid and is enrolled in a Medicaid managed long-term care plan. Harry has been in receipt of Personal Care Services in the amount of 42 hours per week in his home.

On December 8, 2016, the Medicaid managed long-term care plan completed a Uniform Assessment System - Assessment Report of Harry.

On June 23, 2017, the Medicaid managed long-term care plan completed a Uniform Assessment System - Assessment Report of Harry.

Then, a notice was sent to Harry dated July 19, 2017, wherein the Medicaid managed long-term care plan determined to reduce the Harry's Personal Care Services from 42 hours weekly to 28 hours, effective August 3, 2017.

On July 26, 2017, Harry filed for a fair hearing.

Ruling: FOR HARRY.

At the fair hearing the judge first noted that Medicaid regulations provide that a recipient of Medical Assistance or Services has a right to a timely and adequate notice when Medicaid proposes to discontinue, suspend, reduce or change the manner of payment of such benefits. In this case, the judge found that the rationale for reduction in the notice was merely a summary of findings from the "most recent" Uniform Assessment System Report conducted six months earlier, and did not reference any valid reason to support the determination to reduce Personal Care Services. Thus, the judge reinstated Harry's benefits.

Aaron E. Futterman, CPA, Esq. is a partner in the law firm of Futterman & Lanza, LLP with offices in Smithtown, NY and Valley Stream, NY and clients throughout Suffolk, Nassau, Queens, Brooklyn, Bronx, Richmond, New York, Westchester and Rockland Counties. He concentrates his practice to Elder Law, Medicaid Planning, Medicaid Applications, Estate Planning, Probate, Estate Taxes, and Estate Administration.

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