Fair Hearing Experience

Many may think the greatest challenge for Health Home Care Managers is getting a member to consent to services. While getting a member to consent might take a little time, the real challenge is to keep a member in need of services enrolled and engaged. In an ideal world all of our members would be engaged and show progress eventually graduating, no longer needing services. However, we all know life can get in the way.

There are many barriers Care Managers and members might face when it comes to staying connected with one another. Unstable housing, unreliable transportation, lack of communication devices, busy schedules, all of these things can make it difficult to remain in contact even when both parties are working hard to change the circumstances. Based on DOH policy, in these cases, after a certain amount of time with no contact the member is dis-enrolled from Health Home care coordination services.

It is a DOH requirement when dis-enrolling members to send a letter informing the member their services will be discontinued if the member does not contact his/her care manager within 10 days. In the event a member does not respond within the allotted 10 days there is still an option to contest the decision to discontinue services. The member can request a Fair Hearing as long as this is done within 60 days of receiving the notice.

Kate Jancovic, Director of Care Management and Contracts at Human Development Services of Westchester (HDSW), had the experience of participating in a Fair Hearing last summer. HDSW and HVC were one of the first lead Health Home and care management agencies to participate in the Fair Hearing process. HDSW went through the required protocol, sent the member the DOH 5235 informing services would be discontinued and the member requested a Fair Hearing. Before the actual hearing HDSW, HVC, and the New York State Department of Health (DOH) held a conference call to discuss expectations during these types of hearings. HDSW compiled a packet consisting of case notes and all letters sent to the member showing the CMA was attempting to provide Health Home core services on a monthly basis.

After the information was presented to the judge it was left up to the CMA and the member whether services should be resumed. The hearing acted as a forum for the member and CMA to have a discussion and come to an understanding of what is expected if services should be reinstated. Ms. Jancovic states, the Fair Hearing experience was informative and a little bumpy, but having gone through it once will make it easier if future hearings should arise.

As the Office Temporary Disability Assistance OTDA) gains a better understanding of the Health Home Program, HVC believes that the process and experience with OTDA will be a lot smoother and the staff at this office will be able to guide care management agencies and Lead Health Homes on gaining a better understanding of the process and overcome barriers.

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