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The Medicaid Home Care Application Process:A road map to helping your clients navigate andsurvive the application processPractising Law Institute29th Elder law InstituteMarch 22, 2017Presenter: Douglas J. Chu, Esq.475 Park Avenue South26th FloorNew York, NY 10016Tel. # 212-643-1112www.elderlawny.net
Medicaid Home Care:A road map to help your clients get fromapplication to approval for home care servicesYou can only help if youknow how it works.Copyright Hynes & Chu, LLP 2017
Medicaid Services(New York State Rules – your State will have similar rules)Applicant NeedsMedicaid Services*HOME CARENURSING HOME* Cannot apply until you need medical assistance for at least120 days of service. Can not apply before you need medicalcare.Copyright Hynes & Chu, LLP 2017
This is what an applicant must d DenialsConflictFreeEvaluationSelectingan MLTC*providerMLTC*home careassessmentEstablishinga PooledTrustMLTC*reductionin servicesImmediateNeed Medicaid*MLTC Managed Long Term CareCopyright Hynes & Chu, LLP 2017
It takes 3 approvals to obtain Medicaid home careReally like 3 applications being assessed (A B C approval)ApplicantBAFinancialReview ApprovalbyMedicaidCConflictFreeAssessmentHome CareServicesA B CCopyright Hynes & Chu, LLP 2017MLTC*Approval*MLTC Managed Long Term CareProvider
You need to be Eligible : financially and medically 2 - 3 months before home care is in the homeCopyright Hynes & Chu, LLP 2017
What are Medicaid Home Care Services?The home care provider must provide these services within their network,if they are deemed medically necessary Home Care: personal care, light housekeeping, home health aide, visitingnurse, visiting pt/ot , private duty nurse, consumer directed personal assistanceprogram.Adult Day CarePersonal Emergency Response System (PERS)Nutrition -mealsMedical equipment (wheelchairs, medical supplies)Physical, speech and OT outside of houseHearing Aids and EyeglassesPodiatry, Audiology, Dental and OptometryNon-emergency transport to doctor officesEverything else is covered by Medicare – Medicare remains the applicant’sprimary coverage ahead of MLTC Medicaid. Medicaid always secondary.Copyright Hynes & Chu, LLP 2017
Who provides the home care services: MLTC Medicaid(MLTC managed long term care providers : works like an HMO)Only good atVNS ChoiceOnly goodat Guildnet Only good atOnly goodWellCareAt ElderServe 0PlansYou must chose an MLTC planMedicaid will pay a fixed fee eachmonth to the MLTC plan toprovide all home care services.The MLTC plan will arrange for orprovide all Medicaid covered homecare services (care manager)All services are provided by or paidfor by the MLTC plan network–not MedicaidServices provided out of networkmay not be paidIn a small way this is similar to theproposed “Block Grant” or“capitated” Medicaid planproposed by the current Federaladministration.Copyright Hynes & Chu, LLP 2017
The Application for Medicaid Community Based Home CareSTEP #1Surplus IncomeProgramIncome and AssetsNo penalty for transfersof if only applying forhome careAge, Citizenship, I.D.ApplicationMarriage, Divorce,Spousal Refusal ht Hynes & Chu, LLP 2017
The Mystery of Gifting AssetsWithout PenaltyTransferPenalty Imposed?Family/FriendYes, penalty waitNo Penalty waitHomeSweetHomeHome care services permittedduring a penalty periodNursing HomeNo nursing home coverageduring a penalty periodCopyright Hynes & Chu, LLP 2017
Surplus Income and Pooled Trust:Income over 845/month must be contributed like a monthly deductible, unless .Income over 845 Three Possible Options Give the surplus toMedicaid and live on 845 per monthPut surplus in aPOOLED TRUSTPooled Trust canbe spent on things notcovered by MedicaidCopyright Hynes & Chu, LLP 2017Show incurred out ofpocket medical billsequal to surplusPooled Trust is notpart of Medicaid– so they won’ttell you about it.
Pooled Trust Approval processSurplusIncomeThe TrustJoinderAgreementForm tacceptanceletterForm 751EHIPPAReleaseMedicaidApprovaland BudgetLetterVerificationof depositsto TrustForm 486TDeterminationof DisabilitySubmit toMedicaidlegal dept.reviewChose a Pooled TrustZero surpluswww.nylc.com/health/entry/4/Copyright Hynes & Chu, LLP 2017
When to submit the Pooled Trustfor Medicaid approval? Medicaid suggests the Pooled Trust should be submittedwith the initial application However, experience tells us that the necessary legalreview and approval process adds processing time to theover-all approval process Therefore, it is now common practice to submit a Medicaidapplication without the Pooled Trust. Once the applicationis approved, then the Pooled Trust is submitted toMedicaid for approval and a correction to the surplusincome budget will be made.Copyright Hynes & Chu, LLP 2017
Origins of STEP #2: MLTC providers were left in charge of determiningwho they would accept for home care and how much care they wouldprovideFox MLTCP Raised fears of the Fox incharge of the hen house Self interest in taking healthierclients who require less carewould mean more for theMLTC MLTC’s are paid the samemonthly fee by Medicaid, nomatter how many hours of carethey provide to a client Solution Conflict-FreeEvaluation and EnrollmentCenter (CFEEC)Copyright Hynes & Chu, LLP 2017
Conflict Free EvaluationConflict-Free Evaluation and Enrollment Center (CFEEC) STEP #2CFFEC Approved http://wnylc.com/health/download/573Contracted out to MAXIMUS – anindependent corporate contractorDetermines “eligibility” for Medicaidhome care services (120 days ) – theydo not determine number of hours ofhome care – the MLTC will determinehoursIn-home assessment takes about 2 hoursEvaluation is only good for 60 daysAppointment should be approvedwithin 5 – 7 days of callingThe MLTC will not take a case until theCFFEC is completed and Medicaid hasapproved the application.Copyright Hynes & Chu, LLP 2017
Selecting an MLTCYou may change your MLTC plan at any time – once a monthAdvantagePlans(MAP)Programs of All-Inclusivecare for the ElderlyFully Integrated DualAdvantagePACEPlans?PartialMLTCPlansCopyright Hynes & Chu, LLP 2017FIDAPlanPartially CapitatedPlan
Which Plan to Choose?(Two Categories of plans)Provides only Medicaid Home Care Partial MLTC: No effect on Medicare services.You keep your originalMedicare or MedicareAdvantage card. Keep your current “Medicare”doctors – No change to yourMedicare services Medicare remains “primary”health insuranceProvides both Medicaid and “Medicare” services MAP PACE FIDA Provides all services covered byboth Medicaid and Medicare.Must go to doctors and medicalproviders within their network. May need to change yourdoctors, unless your doctor is intheir networkTool for selecting an MLTC www.wnylc.com/health/entry/169Copyright Hynes & Chu, LLP 2017
MLTC Evaluation for ServicesSTEP #3 Contact the MLTCSupply Medicaid approval letter CFFEC approvalHome visit is made and hoursdeterminedYou may apply to differentMLTC’sDifferent MLTC may give morehoursYou may change MLTC when youlike, but it will add a month to theprocess each time you apply toanother MLTC plan 2 hour assessmentCopyright Hynes & Chu, LLP 2017
MLTC Increasing or Reductions of hourswww.wnylc/health/entry/184/ MLTC must give ‘written’ notice of anydecrease or change in hoursRequest increases in writing to the MLTCAny change in hours or denials of serviceincrease may be appealedState Fair Hearing may be requested withcurrent services maintained pending outcome(“aide continuing”) – anytime beforeeffective date of the change.Not required to file internal appeal beforerequesting a Fair HearingSuggestion: First request a Fair Hearing, thenfile an internal appeal. If internal appeal issuccessful (30 day decision), withdraw theFH request.Copyright Hynes & Chu, LLP 2017
Immediate Need ProcessDoes it really get you services faster?www.nylc.com/health/print/203/ Medicaid Alert Medicaid approvalin 7 days Medicaid homecare in 12 days Normal Processtakes 45 to 90 dayson averageCopyright Hynes & Chu, LLP 2017
This is a short cut?1) Complete form toattest to immediate need(OHIP-0103)6) If any forms areincomplete, the case isdeferred pendingcorrections. Notice sentto applicant7) 4 days to accept ordefer the application.Approval within 7 days.2) Doctor must completeMedical Request forhome care form(HCSP-M11q)5) Cover Letterexplaining what youneed – why you need it –and what you aresubmitting8) If all correctlysubmitted, then Homevisit is required to assessthe need for personalcare* within 12 days4) Complete a standardMedicaid application9) If you need more thanpersonal care services,then you must Chose andbe assessed by an MLTC3) Complete HIPPArelease(OCA-960)*Personal Care Services housekeeping, cooking, bathing and toiletingCopyright Hynes & Chu, LLP 2017
Who would use the ‘Immediate Need’ process? Needs personal care from day 1 ofdischarge from a hospitalHas nobody who can provide carepending normal applicationprocessing timeHas no current home care in placeHas no other insurance or Medicarecoverage for what they currentlyneed if they go homeHas urgent immediate needHas someone (hospital discharge)helping they submit an ImmediateNeed application.Copyright Hynes & Chu, LLP 2017
Copyright Hynes & Chu, LLP 2017
Mar 22, 2017 · MLTC Evaluation for Services STEP #3 Contact the MLTC Supply Medicaid approval letter CFFEC approval Home visit is made and hours determined You may apply to different MLTC’s Different MLTC may give more hours You may change MLTC when you like, but
