Medicaid Matters NY , a statewide coalition dedicated to advancing the interests of Medicaid beneficiaries, along with the New York Chapter of the National Academy of Elder Law Attorneys, issued a report this week with findings of an extensive study of fair hearing decisions on reductions of home care service hours by Medicaid Managed Long Term Care (MLTC) plans.
The study examined fair hearing decisions during a 7 month time period. Between June 2015 and December 2015, the study found a sixfold increase in hearings that challenged home-care reductions. In more than 90 percent of those 1,042 hearings, the MLTC member won because either the companies lost or simply withdrew proposed cuts when challenged. The actual number of members that defeated the proposed reductions is likely higher because the data does not include fair hearings that were withdrawn because of settlement. In 8.7% of all of the hearing decisions, the member accepted a partial reduction as a settlement.
In (71%) of the 940 hearings decided fully in the members’ favor, the MLTC plan did not defend its proposed reduction at the hearing. The plan either withdrew its notice of reduction at the hearing (582 cases) or defaulted by failing to send a representative to make its case without formally waiving its appearance, resulting in a favorable decision for the member (89 cases). In the remaining 268 cases decided fully in the members’ favor, a written decision rejected the proposed reduction in hours based on defects with the notice, on the merits, or both. In at least 32% (87) of these decisions, which constitutes 8.3% of all 1042 decisions in the study, the sole basis of the decision was the plan’s failure to send the member legally adequate notice, or any notice at all. In these cases, the member automatically won. Many of the 181 other decisions that reversed a plan’s reduction on the merits also found the plan’s notice to be legally inadequate
The high number of hearings decided because the plan did not show up or ultimately withdrew the proposed reduction is concerning because it seems to indicate the plan knew there was no justification for the proposed reduction in hours. The report notes “For every member who had the wherewithal to request, travel to, and present their case at a hearing, undoubtedly there were many who could not.” It’s unknown how many members accepted a reduction in hours out of concern for losing hours altogether or how many simply had hours reduced without receiving proper notification or knowing their right to appeal.
The report recommends better oversight by New York State Department of Health and that they take proactive measures to attempt to identify other cases where hours may have unjustly been reduced and collect data to better monitor MLTC plans. Click here to read the full report.