Medicaid Managed Fair hearings and Denial of Home Care hours appeals

Representing You At Medicaid Fair Hearings in New York

The Law Office of Inna Fershteyn and Associates specializes in representing elderly clients at fair hearings in Managed Short Term Care Plans, including Senior Health Partners, and Senior Whole Health, Village Care Max, Health Choice. Our experienced NY Elder Care attorney is dedicated to appealing decisions that reduce personal care services hours, ensuring our clients receive the necessary care.

We expertly navigate the complexities of these plans, identifying and contesting errors or unfair reductions. By carefully reviewing each case and gathering essential documentation, we build strong appeals to maintain or increase care levels.

With a proven track record of success, our team is committed to protecting your right to essential care. If you or a loved one faces a reduction in personal care services, trust us to advocate effectively on your behalf.

Pursuant to Section 22 of the New York State Social Services Law and Part 358 of Title 18 NYCRR Ms. Fershteyn appears with clients at fair hearings in New York City, before an Administrative Law Judge.

What are some of the reasons why I might need a Fair Hearing?

Eligibility Issues: If Medicaid determines that you no longer meet the eligibility criteria for short-term care services, and you believe this is incorrect, a fair hearing can challenge this decision.
Service Termination: If Medicaid decides to terminate your home care services or reduce the level of care you receive, you can request a fair hearing to dispute the termination and seek to continue receiving care.
Inaccurate Assessment of Needs: If you believe that the assessment of your care needs is inaccurate, leading to insufficient care or service hours, you can request a fair hearing to correct the assessment and ensure you receive appropriate services.
Delay in Service Authorization: If there is an unreasonable delay in authorizing your home care services and it is impacting your care, you can request a fair hearing to expedite the process.
Incorrect Benefits Calculation: If Medicaid calculates your benefits incorrectly, resulting in inaccurate coverage or care, a fair hearing can address these errors and ensure you receive the correct level of benefits.
Changes in Care Requirements: If your short term care needs change (e.g., you require more intensive care temporarily), and Medicaid’s decision does not reflect these changes, a fair hearing can be requested to adjust your care level accordingly.
Provider Restrictions: If Medicaid imposes restrictions on the providers you can use and you disagree with these restrictions, a fair hearing can help resolve the issue and potentially allow you to use the providers of your choice.
Denial of Home Care Services: If Medicaid denies your request for temporary home care services or reduces the amount of home care support you're receiving, you can request a fair hearing to challenge this denial and argue for the continuation or increase of services.

Why Should an Attorney Represent You in a Fair Hearing?

Having an attorney represent you in a fair hearing offers several advantages:

Expertise and Knowledge: Attorneys specializing in elder care and public assistance law have in depth knowledge of the legal framework and regulations governing these programs. They can identify and leverage legal arguments that you might overlook, significantly enhancing the strength of your case.
Careful Preparation: An attorney can help gather all necessary documentation, including medical records, care assessments, and other critical evidence. They ensure that all paperwork is correctly filed and deadlines are met, which is crucial for a successful outcome.
Effective Advocacy: Attorneys are skilled advocates who can present your case persuasively. They know how to question witnesses, challenge evidence presented by the opposing side, and make compelling arguments on your behalf. This can be particularly important if the case involves complex medical or legal issues.
Stress Reduction: Navigating a fair hearing can be stressful, especially if you are unfamiliar with the process. An attorney can handle all aspects of the hearing, allowing you to focus on your health. Their support can provide peace of mind, knowing that a professional is dedicated to protecting your rights.
Improved Outcomes: Statistics often show that individuals represented by attorneys have better outcomes in fair hearings. An experienced attorney increases your chances of a favorable decision, ensuring you receive the full benefits and services to which you are entitled.

Protect Your Rights. Reverse The Determination to Reduce Personal Care Services With Our Help

Our elder care attorneys successfully argue and reverse the determination to reduce Personal Care Services as under sections of 18 NYCRR 505.14(b) because relevant Agencies frequently fail to meet the following reasons:

Change in Circumstances: Agencies may claim that a client's medical, mental, economic, or social circumstances have changed, justifying a reduction in short term personal care services. For example, an agency might argue that a client's improved health means they need fewer hours of care. Our attorneys ensure that any claimed changes are substantiated and that reductions are necessary.
Mistake in Previous Authorization: Errors in the initial assessment of short term personal care needs can lead to inappropriate service reductions. For instance, a clerical error might have resulted in an incorrect assessment of required care hours. We examine these claims and present evidence to correct such mistakes, ensuring our clients receive the necessary level of care.
Not Cooperating with Assessment: If a client is accused of refusing to cooperate with the required assessment of services, it could lead to a reduction in care. An example might be a misunderstanding during the assessment process. We work to clarify any miscommunications and demonstrate our clients’ willingness to comply with assessments.
Alternative Medicaid Programs: Agencies may suggest that a client can be more appropriately and cost effectively served through other Medicaid programs and services. For example, they might recommend a shift to a community-based program. We evaluate these recommendations to ensure they truly offer comparable or better care without compromising the client's needs.
Health and Safety Concerns: If an agency determines that a client’s health and safety cannot be assured with short term Medicaid services, they may reduce or terminate these services. For instance, they might claim the client's living environment is too hazardous. We provide evidence to counter these claims, demonstrating how existing services are adequate to ensure safety.
Other Programs: Agencies might reduce personal care services if a client participates in another program responsible for providing needed services. For instance, a client using another program might be told they no longer qualify for services. We ensure that all necessary services are provided without unjust reductions.
Rehabilitation and Recovery Support: Short term Medicaid often covers services necessary for rehabilitation and recovery. If these services are reduced or denied, we advocate for the continuation of comprehensive support to ensure full recovery.
Post Hospitalization Care: Clients discharged from hospitals might require short-term personal care services to transition safely back home. We ensure that these post-hospitalization services are provided without interruption to prevent readmission and support recovery.

Our experienced Fair Hearing attorneys and Managed Long term care lawyers successfully challenge New York City's efforts to reduce elderly clients' personal care services, authorized under fee-for-service Medicaid.

FAQs

What is a fair hearing?

A fair hearing is a legal process where individuals can challenge decisions made by public assistance programs, such as Medicaid, SNAP, and other social services. It provides an opportunity to present your case before an impartial hearing officer who reviews the evidence and makes a determination.

How do I request a fair hearing?

To request a fair hearing, you need to submit a written request to the appropriate agency, detailing the decision you are appealing and why you believe it is incorrect. This request must typically be made within a specific time frame from the date of the notice you received about the decision.

What should I bring to a fair hearing?

You should bring all relevant documentation to support your case, including medical records, care assessments, notices from the agency, and any other evidence that demonstrates why the decision should be reversed or modified. Having a detailed and organized presentation can significantly improve your chances of a favorable outcome.

Can I have someone represent me at a fair hearing?

Yes, you can have an attorney or an authorized representative, such as a family member or advocate, represent you at a fair hearing. Having professional representation can help ensure that your case is presented effectively and that all legal arguments are properly addressed.

What happens during a fair hearing?

During a fair hearing, both you and the agency will have the opportunity to present your case. This includes providing evidence, calling witnesses, and making legal arguments. The hearing officer will ask questions to clarify the issues and will later issue a written decision based on the evidence and testimony presented.

What if I disagree with the fair hearing decision?

If you disagree with the fair hearing decision, you may have the option to appeal the decision to a higher authority, such as a state court. The process for appealing will depend on the specific regulations of the program involved, and it is advisable to consult with an attorney to explore your options and the likelihood of success on appeal.

Contact Us Today

You may contact the Law Office of Inna Fershteyn at (718) 333-2394 or contact us online for a consultation request today.