Many applications take months to be ruled on while families rack up big bills.
by Claude Solnik
Morris Wiener, a 94-year-old Medford resident who developed diabetes and a host of other diseases, wanted to stay at home and receive care instead of going to a skilled nursing facility. So his grandson Oren Wiener on March 14, 2008, helped him file an application with Medicaid for home care benefits and contracted with Medford-based Interim Home Health Care, who took Morris Wiener’s case pending Medicaid’s approval of the application.
Although New York law requires county governments’ department of social services to rule on applications within 45 days, Wiener died on June 9 without being evaluated, nearly three months after the application was filed.
The application was denied on Aug. 8, 2008 by Suffolk County nearly five months after the claim was filed. The evaluator said death made it impossible to conduct a medical visit to ascertain whether he would qualify for home care.
Wiener’s family prevailed when an administrative law judge in the Suffolk County Department of Social Services ruled in their favor on Feb. 19, 2010, authorizing $30,000 in Medicaid benefits paid to the home care agency.
Although state law requires applications for home care be evaluated within 45 days, that’s not happening, said Jennifer Cona, managing partner at Melville-based Cona Elder Law.
“Typically, it takes six to nine months to review a home care case,” Cona said. “It’s a violation, but they simply aren’t able to process these cases in 45 days.”
Nassau County said it couldn’t comment on delays since it’s facing a class action suit charging it routinely misses deadlines. But Suffolk County, where 3,380 people on Medicaid received home care as of May, said it generally complies with timeframes.
“The delays are primarily based on applicants and/or their physicians not providing the required information in a timely manner,” said Roland Hampson, a spokesman for Suffolk’s Department of Social Services.
Linda Hassberg, a senior staff attorney at the Empire Justice Center in Central Islip, which filed the class action suit against Nassau County, said delays deprive people of care.
“When people apply for Medicaid, they often have illnesses that require medical attention,” Hassberg said. “Because of the delay, they’re not able to get timely treatment.”
Cona said she’s seeing more cases where benefits are denied because patients die before medical evaluations were completed.
“I had five similar cases where the person passed away, went to a hospital or nursing home,” Cona said. “They [the government] were using the delay to not have to pay any of these people. If they wait long enough, they’ll die, go to the hospital, not be home anymore.”
Hampson said even if patients die, families can still be eligible for payments when the case is decided.
“The death of an applicant generally does not impact the application process,” Hampson said. “If there are medical bills, the determination process would continue.”
And if families win a lengthy and costly legal battle, Wiener said the waiting and wondering takes a toll while they’re caring for loved ones.
“It was not fun, seeing him deteriorate to a point where he couldn’t do anything, remember anything. I had to do his food shopping, dispense his medication,” Wiener said. “At the same time, I had to worry about making sure there’s enough money to pay the home care agency.”
While Wiener said Interim Home Health Care eventually got paid, some home care agencies refuse to take cases where there’s no clear decision as to who will pay, forcing families to pick up costs or forego care.
Other companies that take Medicaid-pending cases can end up on the hook for months.
“It’s a problem for the family and the agency that’s expecting the payment,” said Eileen Gerard, director of human resources for Oakdale-based South Shore Home Health Services. “The agency tries to collect from the family, which can’t afford to pay the agency. It could lead to collections, especially if the patient dies.”
Cona said the county and state could benefit by delaying or denying payments in the hope that this will lead to lower costs.
But she said denials of home care, in the end, may lead to higher costs as people head into nursing homes.
“It would save the state money if they allowed people to stay at home,” Cona said. “We have this battle with them all the time. It is less expensive for people to stay home. We should make it easier for people to stay home.”