A mistaken mistake

Photo of Dortha Shay, an elderly white woman with white hair, sitting at her dining room tableDorotha Shay is 91 years old and lives in Steuben County in Western New York with her 70-year-old daughter. Her Medicaid Managed Long Term Care (MLTC) plan approved her for home care services so she could continue living in her own home.

One day her MLTC plan sent her a notice stating that they would reduce her home attendant hours from 138 to 48 hours per week, a reduction of 72%. Her plan claimed there was a mistake in the previous determination of hours.

Dorotha’s daughter was very concerned that her mother could no longer live at home with fewer hours of home care. She requested an appeal of the plan’s decision, but the plan denied the appeal. She didn’t know that it is quite common for MLTC plans to deny these appeals. She requested a Medicaid Fair Hearing, but didn’t know what to do next.

She contacted the local Office for the Aging, who referred her to Stephanie, an ICAN advocate at Legal Assistance of Western New York. Stephanie reassured her that she had a good chance of winning the Fair Hearing. She guided Dorotha’s daughter through the Fair Hearing process, and helped her obtain medical documentation of need, including a journal of home care tasks and a personal narrative.

With this guidance, she successfully convinced the judge that her mother’s prior approval for 138 hours was not a mistake, but medically necessary. The judge ruled that the plan’s decision to reduce the hours was the mistake, and ordered them to keep Dorotha’s hours at the same level.

Dorotha’s daughter said, “I appreciate the manner in which Stephanie graciously walked me through the appeals process and helped me during this stressful time. She was professional, empathetic, and thorough. I am grateful for the part ICAN and Legal Assistance of Western NY played in allowing me to keep my mother at home. Her medical and social needs are more adequately met with the one-on-one care she receives in a loving and supportive environment.”