New Jersey Family Care is the Medicaid a program that provides MLTSS — Medicaid Long-Term Services and Supports. The home care program is called HCBS — Home and Community-Based Services. Once the applicant has been found eligible for Medicaid and is assigned a Medicaid case number, s/he must select a Managed Care Organization (MCO). S/he will then receive a visit from a Case Manager from the MCO, who will determine the number of hours of services which will be provided. See prior posts for more discussion about that process. This initial determination is appealable.
The case will then be reviewed periodically. Reviews are usually done done every six months, using a MCO tool that conforms with state Medicaid guidelines. The MCO has a vested interest in keeping the hours of service as low as possible, which creates a conflict with the aged person who wishes to age in place in the community, but this is balanced with the MCO’s obligation to reduce risk and prevent institutionalization. Hours cannot be arbitrarily reduced. The MCO must be able to document that there has been a change in the Medicaid participant’s condition which justifies the reduction of services, unless hours were awarded prior to MLTSS by another MCO. Here, here and here are three good recent examples of Final Agency Decisions in cases that involved reductions in hours.
The goal is to keep people at home and out of nursing homes.As the advocate for the Medicaid participant, you can monitor the services provided as well as the capability of the individual and whether there has been any improvement in their health condition or their ability to take care of him/herself. This will provide you with some of the ammunition needed should you be faced with a notice of reduction in hours.
Call us for advice on Medicaid eligibility, applications and appeals … 732-382-6070