Appealing reductions in PCA hours under Medicaid

If the State Medicaid program cuts your hours of service, appeal, appeal, appeal. NJ Medicaid  administers certain of its home care services through a program called the Personal Preference Program. The number of allocated hours of service is decided by the Division of Medial Assistance and Health Services (DMAHS). Personal Care Assistant (PCA) services are provided to the participant at a set hourly rate, and the DMAHS cash grant to the participant is calculated accordingly. From time to time, through a review and screening assessment, DMAHS may review the hours and issue a Notice of Reduction. The participant has the right to appeal. The Division of Disability Services can carry out an independent assessment, and the participant retains the right to appeal that decision. Hearings can be had at the Office of Administrative Law before an Administrative Law Judge. DMAHS makes the Final Agency Decision, and that can be appealed to the Appellate Division of Superior Court.

In a case decided yesterday, the Appellate Division vacated a major reduction in hours in the case of D.W. v. DMAHS and Division of Disability Services, docket no. A-0384-13T4 (decided Dec. 15, 2014).a0384-13. The case was not approved for publication, which means it is not binding on other tribunals. In this case, D.W. was 48 and had severe disability due to Down’s Syndrome leaving her with the mental capacity of a four year old child. She was totally dependent in her Activities of Daily Living and had additional medical conditions which further complicated her care. She had been receiving 40 hours of PCA services since 2009.  When her HMO reassessed her, the hours were reduced by 50% to 20 hours/week. She requested a hearing, was reassessed, and 25 hours/week was recommended. She appealed. The Appellate Division found that there was no dispute that D.W.’s condition had deteriorated since 2009, yet there was no evidence in the record explaining why a reduction was warranted. The Agency’s reliance on its newer assessment tool was apparently insufficient proof. The Court vacated the decision and remanded for reconsideration by DMAHS.

In this case, the participant requested that the reduction of hours be stayed pending appeal. That stay was continued by the Court.

Call for representation concerning Medicaid eligibility and notices of reduction … 732-382-6070

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