I Wish Someone Would Tell Me the Truth About What Needs Qualify for 24-Hour Care Under the Medicaid Home Care Program

Securing 24-hour care under the Medicaid home care program can be a complex and often misunderstood process. Many families struggle to understand why their loved ones, who clearly need continual care and assistance, are only approved for a few hours of care per day. Understanding the criteria and how they are applied can help you navigate this challenging process and ensure that your loved one receives the appropriate level of care.

Activities of Daily Living and the Task-Based Assessment Tool

Medicaid typically pays for home health aides to assist with activities of daily living (ADLs). These include walking, dressing, bathing, toileting, cooking, eating, and transferring. Managed Long Term Care (MLTC) plans in New York use a task-based assessment tool to determine the number of care hours a person will receive. This tool assigns a specific number of minutes to each ADL and then adds these minutes up to establish the total amount of care time they will authorize.

However, because of the way this tool is designed, the minutes per task typically add up to no more than six or seven hours per day. This is because the tool does not account for the time needed beyond the completion of specific tasks. As a result, it often underestimates the true care needs of individuals who require continuous care and assistance.

The Misconception About "Safety Monitoring"

A critical issue arises when MLTC plans categorize the need for ongoing supervision as "safety monitoring," which they claim is not covered under Medicaid. Safety monitoring refers to the general oversight of a person to prevent harm, such as falls, when no specific ADL is being performed. However, this does not encompass all scenarios where supervision might be necessary.

For instance, consider a person who is bedbound and cannot transfer from their bed to a wheelchair without assistance. While the physical act of transferring might only take a few minutes, this does not mean the individual can be left alone for the rest of the day. They may need multiple transfers throughout the day, assistance with toileting, or regular repositioning to prevent bedsores, especially during the night. This need for ongoing assistance and supervision goes beyond simple safety monitoring and directly relates to the person's ADLs.

Legal Clarifications and the Need for Continuous Care

The law (GIS 03 MA/033) clearly distinguishes between standalone safety monitoring and supervision required as part of assisting with ADLs. When a person needs constant supervision in conjunction with these activities, the requirement for round-the-clock care becomes evident. For example, a wheelchair-bound individual may need unscheduled help with toileting multiple times a day or require diaper changes every few hours to prevent skin breakdown. These needs cannot be adequately addressed by simply adding up minutes in a task-based tool.

Ensure You Get the Care You Deserve

It's crucial to understand that if your loved one needs someone with them at all times due to their inability to perform ADLs independently, they may be entitled to 24-hour care under Medicaid. If you're facing difficulties securing the appropriate level of care, you don't have to navigate this complex system alone.

Click below to receive our book, which provides a detailed guide to understanding and navigating the Medicaid home care process. Alternatively, call us for a consultation at (718) 740-3300. Let us help you ensure your loved one receives the comprehensive care they need and deserve.