It’s something we hear all the time – that someone “can’t be left alone” and requires “twenty-four hour care”. But obtaining twenty-four hour home care through Medicaid is not as easy as it once was. Here, we discuss different ways in which someone may receive twenty-four hour Medicaid home care, who may provide it, how to obtain it, and what you can do if you are not approved.
There are two ways in which someone may receive twenty-four hour home care, split-shift and live-in.
“Split-shift” means that a patient receives two twelve-hour shifts of home attendants every day. This is meant to ensure that there is a always an awake home attendant available to care for the patient. Since changes to the Medicaid system in 2011, in our experience, it has become difficult for new Medicaid home care recipients to obtain approval for split-shift care. The primary culprit being the costs associated with providing such care. Under the new Medicaid system, providers receive episodic or capitation rates and are not reimbursed more for providing more services. Split-shift care is extremely costly and providers stand to lose tons of money by providing that level of care. [Note: This is a practical observation and it does not mean that providers are technically absolved from providing split-shift care. We have seen split-shifts approved on rare occasions.]
“Live-In” means that a single home attendant stays with a patient for twenty-four hours. The patient’s residence will require a place for the home attendant to sleep. Home attendants are not paid an hourly rate for 24 hours for these cases. Rather, they receive a daily rate that is in the range of roughly 13 hours of work (billed hourly). The lower rate is rationalized by the argument that the home attendant is not expected to be working for the full 24 hours. While providers do not like to approve live-in care, we find that it is available for those that truly need it.
There are two types of mainstream providers that approve home attendant hours, Certified Home Health Agencies (CHHAs) and Managed Long-Term Care (MLTC) plans. We find that people who receive Medicaid services from a CHHA usually are not approved for more than 8 hours a day, and often substantially less than that. With MLTC plans however, we find that at least some plans will provide 24 hour live-in care for those that truly need it.
That being said, while someone may not be able to obtain 24 hour home care from a CHHA, it may still be worthwhile for them to pursue CHHA services while they work on enrolling into a MLTC plan. CHHA services can often be put in place much faster than enrolling someone into MLTC. The CHHA services can then serve as a bridge while the patient works towards obtaining 24 home home care from a MLTC plan.
The first step when looking to obtain 24 hour home care is to seek a provider that is at least willing to provide it when necessary. As stated above, we have found that 24 hour home care is usually only approved by MLTC plans. Historically, we have found that not all MLTC plans are the same when it comes to approving 24 hour care. Some are more generous than others. [Note: The implementation of the Conflict-Free Evaluation and Enrollment Center (CFEEC) may help even the playing field to a degree, but we still anticipate differences among plans in the amount of hours authorized (The CFEEC makes an independent assessment of all new patients seeking to enroll in MLTC).]
In light of this, it can be helpful to seek guidance from someone who has experience with assisting people in obtaining home care through MLTC. They can steer you in the direction of a MLTC where you will have a better chance of being approved.
Once you have identified the MLTC you would like enroll with, back up your request. A lot of people “want” 24 hour home care. Demonstrate to the nurses that come to assess (from the CFEEC and the enrolling MLTC) that the patient in fact “needs” 24 hour home care. That it would be unsafe to leave the patient alone for ANY period of time. Cite examples such as the patient waking up in the middle of the night, and then wandering or falling. If you can procure a letter from the patient’s doctor supporting the need for 24 hour home care, so much the better. Show the nurse that the actual needs of the patient are in-line with your request for 24 hour care. [A bit of caution: Sometimes when a patient’s need is extremely great, providers will decline to provide any services stating that the patient is “unsafe for home care” and “requires a higher level of care”. Be certain to demonstrate that the patient will in fact be safe at home if she receives 24 hour home care.]
Another thing to be aware of is that many people that need home care do not like to admit it. This can become a problem when the nurses come to assess if the patient creates the impression that they don’t really need that much help. It may be helpful to have a respectful conversation with the patient before the assessment explaining the importance of communicating their true level of need. Another option can be to speak with the nurse for a few minutes before she enters to make the assessment, outside of earshot of the patient, explaining that the patient is sensitive about her needs but that in fact she needs substantial help.
Just because a MLTC plan sent a nurse to evaluate you, that does not obligate you to enroll with them. If you are not satisfied with the services being offered by the plan, you may decline enrollment and request that you be evaluated by a different MLTC plan. Bear in mind that enrollments are done on a monthly basis and if someone misses the cutoff for a given month, they will have to wait an entire month before they can be enrolled in any MLTC plan. It may be worthwhile to first enroll with a MLTC, ensuring at least some MLTC services for the coming month, and then work on switching to a MLTC that will approve 24 hour home care.
If you are not approved at all for 24 hour home care, all need not be lost. As discussed above, live-in home care is usually billed at a daily rate that is roughly in the range of 13 hours of home care. You can likely contract with the licensed home care services agency (LHCSA) that is providing the home attendant to pay extra and have the attendant stay for 24 hours. This may not be that costly. For example: If someone is approved for 12 hours a day of home care from their MLTC plan, they may be able to contract with their LHCSA to have the home attendant stay for 24 hours for roughly the cost of 1 hour of home care a day.
Please Note: This article covers what we consider basic, practical knowledge that we believe a savvy consumer should be aware of when pursuing 24 hour home care. This article does not cover more advanced techniques such as filing appeals and requesting fair hearings. For a discussion of these things, see here.
We provide free assistance to people who are looking to receive 24 hour Medicaid home care. While results vary, we have successfully helped many clients get 24 hour Medicaid home care. If you would like assistance for yourself, a loved one, or a client, please give us a call. Call Us Now! 718-838-3838