Home Care

Following an extended period of hospitalization, Alexander's health plan terminated his coverage. In an effort to assist him, we brought the case to a Fair Hearing. Subsequent to the Fair Hearing proceedings, the Administrative Law Judge issued a favorable ruling. Despite this decision, the attorney representing the Managed Long-Term Care plan expressed reluctance to abide by the judgment. To ensure compliance with the legal ruling, we successfully enlisted the participation of supervising judges. As a result, Alexander's health plan was fully reinstated, and it granted him the necessary coverage.

To ensure her health and safety, Evelyn required around the clock home care services. Unfortunately, the MLTC plan rejected our appeal, so we escalated the case to the Fair Hearing level. The plan's attorney mistakenly argued that we couldn't represent Evelyn because she wasn't legally incapacitated, and thus ineligible to appoint a health care proxy. As a result, the hearing was postponed pending further clarification of the Health Care Proxy law. However, after our thorough inquiry, the agency level review was initiated, leading to a positive outcome for Evelyn.

Jonathan, who is severely disabled, was unjustly denied his request for around-the-clock home care services, a total of 168 hours per week. Instead, the plan only authorized a total of 42 hours per week. This denial resulted in significant safety concerns stemming from the lack of adequate home care. Additionally, his situation was further complicated by the risk of falling. This became particularly challenging as his caregiver of many years was no longer able to provide assistance during the night hours due to the advanced weakness caused by her cancer. However, following an expedited 72-hour external appeal process that we set in motion, we were able to assist Jonathan with getting the adequate level of home care services, a total of 168 hours per week.

Due to her medical diagnoses, Ella required around-the-clock home care services. However, her Managed Long Term Care plan was only willing to authorize a mere six hours per day. Moreover, the plan wrongfully delayed her internal appeal request, causing an indefinite delay and preventing Ella from filing for a Fair Hearing.

Following guidance from the state regulatory agency, we proceeded to request a Fair Hearing without waiting for the final determination from the plan. To further complicate the matter, the Fair Hearing had to be adjourned twice due to the judge's limited knowledge of the rules and regulations governing the home care appeal process. Consequently, a replacement judge was assigned.

Once the Fair Hearing was ultimately conducted, we presented a compelling case that persuaded the judge to rule in Ella's favor, mandating the provision of the requested level of home care services.

Sarah, a severely disabled person who is also legally blind, struggled to find the assistance she desperately needed, finding herself in a very difficult situation. Despite the obvious medical need and a history of falls resulting in serious injuries, such as fracture of her nasal bones, after a Fair Hearing, held at her residence, a Supervising Administrative Law Judge denied her request to continue receiving round-the-clock home care services. This ruling drastically cut down her 168 hours of care per week that had been in place for nearly a year to just 42 hours, placing Sarah in an unsafe situation. However, working extended hours, we were able to expeditiously restore the medically necessary round-the-clock home care services through the appeal process, safeguarding her well-being.