Florida Medicaid Home and Community Based Services Appeals

Sarasota elder law attorney protects eligibility to state programs

If you are receiving or have applied to receive Medicaid Home and Community Based Services (HCBS) in your home and believe you are not receiving the required number of hours to maintain your health or meet your current needs, Teresa K. Bowman, P.A. in Sarasota can file an appeal for you. As a Florida attorney certified by the National Elder Law Foundation, I understand the complexities of the system and the requirements Medicaid recipients must satisfy to receive services at home or in their community. My firm understands how HCBS can prevent institutionalization and significantly improve the quality of a recipient’s life. Don’t hesitate to reach out if you are unhappy with Medicaid’s decision. 

Overview of Medicaid Home and Community Based Services (HCBS)

Under Florida law, the state’s Agency for Health Care Administration (AHCA) is responsible for managing the Medicaid program. As part of this responsibility, ACHA privatized home and community-based services and contracted with several Medicaid health plans to coordinate care with local providers to meet the needs of enrollees. Specific health plans that are part of this process include Aetna, Community Care, Humana, Molina, United Healthcare and Sunshine. These companies are paid a negotiated rate for each Medicaid enrollee. The health plan then contracts with local care providers to deliver hands-on care in the home or community. 

To receive HCBS benefits such as in-home assistance or care in an assisted living community, an applicant must demonstrate that their medical condition prevents them from handling the activities of daily living on their own and that no one in their household is capable of providing this help. Applicants also have to show that they qualify financially based on a review from Florida’s Department of Children and Families. In a phone interview, applicants are asked a series of questions about their health, daily activities and any help they currently have with meeting daily needs. Based on the discussion, the interviewer assigns a score assessing the urgency of the applicant’s needs. Unlike some other Medicaid programs, there is a lack of funding for home and community-based programs, so some claimants who qualify are put on a waitlist. Moreover, the number of hours needed to provide adequate care is often not approved by the health plan, resulting in unmet needs. This gap directly conflicts with the goals of the HCBS waiver program.

Common issues and reasons for denial

Having someone come to your residence to assist with personal care, meals and other challenges of daily life can be life-changing, saving an elderly person from having to enter a nursing home. Unfortunately, there are many justifications health plans use to deny requested services in whole or in part, such as:

  • Applicant’s medical condition does not require the assistance requested
  • Hours of in-home service requested are more than required based on the health plan’s assessment
  • Family members can provide care to supplement any unmet need

You do have the option to appeal if your health plan refused to authorize sufficient hours for your in-home assistance. I am a seasoned elder law attorney who is well versed in the complexities of the Medicaid system and the reasons companies give for denying seniors the services they deserve. 

Understanding the Medicaid HCBS appeals process

Your health plan is required to offer a process to have grievances and appeals reviewed. After receiving an adverse benefit determination, you have 60 days to file an appeal with the health plan. From there, the plan has 30 days in which they can affirm or reverse the decision. If you are still not satisfied with the outcome, you can seek what is known as a Fair Hearing before ACHA.  

Legal representation for HCBS appeals

Appealing a health plan denial is difficult in any situation, but can seem impossible for a senior who is already dealing with medical challenges on a day-to-day basis. It is vitally important to retain a Florida Medicaid lawyer who can gather the documentation needed to reverse an unfair decision and advocate for you throughout the appeal process. Should the health plan refuse to change their decision, I will represent you in the Fair Hearing before ACHA that you are entitled to under the law. 

Advocacy for assisted living and skilled nursing issues and grievances

My firm provides effective counsel for a wide range of elder law issues, including the creation of trusts that help clients maintain eligibility for Medicaid benefits. Along with HCBS, I also provide advice and advocacy to individuals whose situation necessitates assisted living or a skilled nursing home facility. Whether you are just starting your planning for long-term care or have a question about the grievance and appeals process, my firm is ready to help you. 

Contact a Florida lawyer about a Medicaid Home and Community Based Services appeal

Teresa K. Bowman, P.A. in Sarasota represents Floridians in appeals from decisions involving Medicaid Home and Community Based Services. If you feel you are not receiving the number of care hours you require, or if you feel the healthcare plan is not meeting your needs in other ways, please call 941-735-0811 or contact me online to schedule a consultation where we can discuss your situation and options.