Home Care Hours Cut or Denied? How to Appeal in New York

A letter arrives saying your mother’s hours are dropping from 40 a week to 25. Or that the increase you asked for is denied. Most families read it, feel sick, and assume it is settled.

It is not settled. New York has a formal appeal structure for Medicaid managed care, and reductions are overturned or reduced regularly — particularly when the family produces evidence the assessment missed. What decides the outcome is almost always what you do in the first ten days.

Step 1: Read the Notice and Diary the Dates

The plan is required to send a written Initial Adverse Determination notice, and for a reduction or discontinuation it must arrive at least 10 days before the change takes effect. The notice must say what is changing, why, and how to appeal.

Write down two dates immediately: the date on the notice, and the effective date of the change. Every deadline below is counted from one of them.

Step 2: Request Aid Continuing — This Is the Urgent One

Aid continuing means your current hours stay in place while the appeal is decided. Without it, the reduction takes effect on schedule and you fight to get the hours back later.

To get it, you must request it within 10 days of the notice date, or by the effective date of the change, whichever is later. Ask for it in the same breath as filing your appeal, and ask in writing as well as by phone.

This single step is the difference between a stressful few weeks and a genuine crisis at home.

Step 3: File the Plan Appeal (Internal Appeal)

In New York you must go through the plan’s own appeal before you can get a State Fair Hearing. You have 60 calendar days from the date on the Initial Adverse Determination to file.

• Put it in writing even if you also call. Keep a copy with the date.
• Ask the plan for the file — the assessment, the care plan and the clinical rationale used to make the decision. You are entitled to see what it was based on.
• Request an expedited appeal if waiting would seriously jeopardise health or safety. Expedited appeals are decided within 72 hours.

Step 4: If the Plan Upholds It — State Fair Hearing

If the appeal comes back as a Final Adverse Determination, you have 120 calendar days from that notice to request a State Fair Hearing, where an administrative law judge reviews the decision independently of the plan.

Ask for aid continuing at this stage too — request it promptly after the Final Adverse Determination so your hours are not interrupted while the hearing is scheduled.

For medical-necessity denials, an External Appeal by an independent clinical reviewer may also be available. The plan’s notice will tell you whether your situation qualifies.

What Actually Wins These Appeals

Procedure gets you into the room. Evidence wins. In our experience the families who succeed bring some version of the following:

If the underlying issue is that the original assessment did not capture the reality, read how the approval process works and prepare properly for any reassessment.

Should You Change Plans Instead?

Sometimes, but not usually mid-appeal. Switching plans restarts assessment and authorisation, and you lose the aid-continuing protection attached to the current dispute. If your plan has been consistently difficult, look at it after the appeal resolves — see how to choose an MLTC plan and how MLTC plans work.

Covering the Gap

If hours do drop while you appeal, families commonly bridge with private-pay hours for the shifts that matter most — usually evenings, nights or weekends. Our respite guide covers the other routes to relief, and if you are carrying the extra load yourself, read caregiver burnout.