21 Jun How to get more home care hours in Pennsylvania: A Guide
Are you a client or a caregiver working with a client that receives home care services through the Medicaid waiver in Pennsylvania? Does your client have a need for additional hours but don’t know where to start? Alternatively, did your have a set number of hours that were cut? Find out the process on how one can go about getting more hours below, whether you’ve recently been denied for additional hours, or want to know where to begin.
Note: This guide is for those individuals currently on the Medicaid waiver program and with one of the three health plans serving those members in Pennsylvania, including Keystone First, PA Health and Wellness, Amerihealth Caritas, and UPMC. If you are not yet on the Medicaid waiver program, also known as Community HealthChoices, read our guide here on how to get started on getting home care services in Pennsylvania.
If at any time you have questions about this process, feel free to reach out to the Chosen Family Home Care team and contact us here. Chosen Family Home Care partners with participants to make sure to help provide them with the education and knowledge to get their care. We can help guide participants that are a part of the organization to help them through this challenging time.
Click below to navigate directly to your particular situation:
Situation 1: I am currently receiving home care sevices under Community HealthChoices through Keystone First, Amerihealth Caritas, UPMC, or PA Health and Wellness. I have an approved number of hours, and I requested more but that request was denied.
Situation 1: I am currently receiving home care sevices under Community HealthChoices through Keystone First, Amerihealth Caritas, UPMC, or PA Health and Wellness. I have an approved number of hours but those were decreased or reduced by the health plan.
Most likely, either your designated Service Coordinator or a member of the health plan authorization team will reach out to you to let you know of the denial or your cut in hours. Your home care agency, such as if you were with Philly’s top agency Chosen Family Home Care, will likely get notified. Sometimes, the home care agency will know about the cut in home care hours or hours increase denial before the participant. Also, the health plans are required to notify the participants and the home care agency as well via USPS post office mail.
You will be formally notified about the appeals/grievance process. An appeal is what you will file if you do not agree with your health plan’s decision. How you proceed will depend on which health plan you have. We will focus on Keystone First appeals and grievances as well as PA Health and Wellness, and they are the most common CHC insurance plans in Pennsylvania as well as Philadelphia.
Step Three (Keystone First)- For PA Health and Wellness process, proceed to the next step below
What is Keystone First’s phone number for complaints?
Call Keystone First CHC at 1-855-332-0729 (TTY 1-855-235-4976) and tell Keystone First CHC your Complaint, or
• Write down your Complaint and send it to Keystone First CHC by mail or fax, or
• If you received a notice from Keystone First CHC telling you Keystone First CHC’s decision and the notice included a Complaint/Grievance Request Form,
fill out the form and send it to Keystone First CHC by mail or fax.
What is Keystone First’s fax number for complaints?
You can use Keystone First CHC’s address and fax number for Complaints and Grievances:
Keystone First CHC
200 Stevens Drive
Philadelphia, PA 19113-1570
Fax number: 1-855-332-0141
There are time limits on it, but for standard appeals/complaints/grievances, the time period for submission is 60 days.
You can read all about Keystone First complaints and grievances right here in their Keystone First complaints and grievances manual. The manual goes over the full process for appeals, grievances, and complaints, including all of the complaint tiers as well as further appeals and grievance processes.
For example, after two complaints, one can then escalate the matter for an external complaint review. This can be filed with the following:
Pennsylvania Insurance Department
Bureau of Consumer Services
1209 Strawberry Square
Harrisburg, PA 17120
You can even file a complaint with the Pennsylvania Insurance Department online at this link!
What to do to continue getting services:
If you have been getting the services or items that are being reduced, changed or denied and you want to continue getting services, you must ask for an external
Complaint review or a Fair Hearing within 10 days of the date on the notice telling you Keystone First CHC’s First Level Complaint decision that you cannot get services or
items you have been receiving because they are not covered services or items for you for the services or items to continue until a decision is made. If you will be asking for
both an external Complaint review and a Fair Hearing, you must request both the external Complaint review and the Fair Hearing within 10 days of the date on the notice
telling you Keystone First CHC’s First Level Complaint decision. If you wait to request a Fair Hearing until after receiving a decision on your external Complaint, services will
In some cases you can ask the Department of Human Services to hold a hearing because you are unhappy about or do not agree with something Keystone First CHC did or did not do. These hearings are called “Fair Hearings.” You can ask for a Fair Hearing after Keystone First CHC decides your First Level Complaint or decides your Grievance.
How Do I Ask for a Fair Hearing?
Your request for a Fair Hearing must be in writing. You can either fill out and sign the Fair Hearing Request Form included in the Complaint or the Grievance decision notice
or write and sign a letter.
If you write a letter, it needs to include the following information:
Your (the Participant’s) name and date of birth;
A telephone number where you can be reached during the day;
Whether you want to have the Fair Hearing in person or by telephone;
The reason(s) you are asking for a Fair Hearing; and
A copy of any letter you received about the issue you are asking for a Fair Hearing about.
You must send your request for a Fair Hearing to the following address:
Department of Human Services
OLTL/Forum Place 6th FL
CHC Complaint, Grievance and Fair Hearings
P.O. Box 8025
Harrisburg, PA 17105-8025
Step Four (PA Health and Wellness)
PA Health and Wellness Community HealthChoices will follow a similar process as Keystone First. The major difference is where and how to file a complaint or grievance.
You may file a complaint or grievance via phone, fax or mail for PA Health and Wellness one of the following ways:
- Call 1-844-626-6813 and TTY 1-844-349-8916
- Fax 1-844-873-7451
- Write and mail to PA Health & Wellness, Attention Complaint and Grievance Unit, 300 Corporate Center Drive, Camp Hill, PA 17011
If you want more hours, the first thing to do is contact your Service Coordinator, or SC. If you don’t know who the SC is, you should call your respective health plan and ask them to connect you to the Service Coordinator. Those numbers are below:
PA Health and Wellness Community HealthChoices Participant Line: 1-844-824-3655
Keystone First Participant Line: 1-855-332-0729
Your Service Coordinator should schedule an additional assessment to discuss your request for more hours.
Once the SC submits the request, the participant wait for the health plan’s decision. If the health plan denies the request, the participant can then follow the complaint/grievance/appeal process as outlined above.
Tips For Requesting More Hours and Fighting Denials
Tip 1: Request the assessment or assessments done that the decision was based on.
You can review it for inconsistencies or inaccuracies in determining why you want more hours and/or why you think the denial was wrong. This can be the baseline for your appeal and our hours increase request.
Tip 2: Look for inaccuracies in the report.
This can help you fight a denial or help you in your request for more hours.
Tip 3: Be sure to have documentation or evidence to prove your case.
In requests for an appeal or more hours, it helps to have additional documentation and records that prove your case. Ask for doctors’ records that help with the evidence.
Tip 4: A doctor’s note is not necessarily a justification for an increase in home care hours
Just because the patient’s doctor signs a letter stating that the participant or patient needs a certain number of hours does not mean that the health plan has to give it to the participant.
Tip 5: You must file any relevant appeals on time.
The health plan’s written denial must include how and when to appeal the decision. Be sure to file your appeal before the deadline date. If your appeal is late, you automatically lose. Plus, even when you get the appeal in on time it can take weeks to get a response. Therefore, the earlier the better.
Tip 5: Request a Fair Hearing.
Fair hearing requests are the last step in the process. Be sure to provide as much evidence and documentation as possible to prove your case.
How Chosen Family Home Care Can Help
Chosen Family Home Care is an advocate for all of our clients and patients. Reach out to us today and we can assist in helping you with your appeals process and helping you get the home care hours in Pennsylvania that you deserve. Contact us now!