7 Ways to Advocate for the Right Number of Home Care Hours Through MLTC

Getting approved for home care through MLTC can feel like a win-until you realize the hours don’t match real life. Maybe mornings are hard, nights are riskier, or your loved one can “technically” do tasks but not safely or consistently. The key is knowing that you can ask for more hours, ask again, and escalate when needed-while backing your request with clear, practical proof.

Below are seven ways to advocate effectively, without turning your home into a courtroom or your loved one into a “case file.”

1) Describe the week, not the diagnosis

Assessments and care planning are built around daily functioning: bathing, toileting, transfers, meal prep, mobility, medication routines, and safety. So when you speak with the plan/care manager, walk them through a typical week:

• What happens in the morning (getting up, bathroom, dressing, breakfast)?
• What’s hardest after lunch (fatigue, confusion, missed meds, falls risk)?
• What happens at night (bathroom trips, sundowning, pain, supervision needs)?
• Where are the “danger zones” (stairs, shower, cooking, clutter)?

This shifts the conversation from “They have arthritis” to “They cannot safely get in/out of the shower without standby help.”

2) Keep a simple 7-14 day “care log” (the most underrated tactic)

You don’t need anything fancy-just a note on your phone or a paper list. Track:

• Near-falls or actual falls
• Missed meals / dehydration
• Medication mix-ups (missed or doubled)
• Toileting accidents / night frequency
• Times when someone had to intervene for safety
• What family members did (and how long it took)

When you request more hours, that log becomes your evidence-much stronger than general statements like “We’re struggling.”

3) Be honest about what family is already doing (even if it feels “normal”)

MLTC decisions often consider informal support. If family is quietly covering huge gaps-daily rides, cooking, med setup, bathing help, overnight supervision-say it plainly. If it’s not sustainable, say that too.

A common trap: families under-report help because they don’t want to sound like they’re complaining. But if you don’t name the unpaid labor, it can look like needs are already covered.

4) Request an increase through the care manager, in writing when possible

Many consumer-rights guides emphasize that members can request an increase in services at any time by contacting the care manager.
When you ask, be specific:

• “We need coverage for mornings (7-11am) for bathing, dressing, breakfast, and safe transfers.”
• “We need evening support for dinner, medication reminders, and toileting safety.”
• “We need overnight coverage due to high falls risk during nighttime bathroom trips.”

If you can, follow up any phone request with a short written message (email or portal message) summarizing what you asked for and why.

Include your one-liner anchor text exactly once like this in your article request or documentation, if needed: MLTC agency.

5) Align your request to safety and medical risk (not convenience)

Plans are much more responsive when the request is framed around preventable harm:

• Falls risk (bathroom transfers, stairs, dizziness)
• Medication safety (cognitive changes, complex schedules)
• Skin integrity (incontinence, hygiene barriers)
• Nutrition/hydration risk (skipped meals, weight loss, dehydration)
• Cognitive/behavioral safety (wandering, confusion, leaving stove on)

Even if the feeling is burnout, the argument that moves decisions is usually safety + functional need.

6) If hours are denied or reduced, use the grievance/appeal ladder fast

If the plan issues a denial/reduction/termination, you generally have the right to file a grievance or appeal (orally or in writing).
Also, guidance for managed care appeals in New York frequently stresses timing-especially if you want services to continue while the appeal is pending (“aid continuing”). Some advocates note you may need to request the appeal quickly (often within 10 days of the notice date) to keep services from changing during the appeal process.

Practical move:

• Call and ask for the plan’s appeals unit and instructions.
• Submit a short written appeal that restates the core risks + the schedule gaps.
• Explicitly ask for services to remain in place while the appeal is reviewed (when applicable).

If the internal appeal isn’t resolved in your favor, you can request a State Fair Hearing within the stated timeframe (commonly referenced as 120 days in NY plan materials and advocacy resources).

7) Bring backup: doctor letters + specific “prescription-level” detail

A generic note like “needs home care” is weak. A strong letter includes:

• Diagnoses plus functional impact (cannot bathe independently; requires assist for transfers)
• Fall risk history (dates if possible)
• Cognitive/behavior concerns (confusion, poor safety awareness)
• A recommended coverage pattern (e.g., “daily morning assistance” / “evening supervision” / “overnight due to toileting-related falls risk”)
• Any recent hospitalization/ER visits and why

If you can get physical therapy or nursing notes that describe mobility limits, that can help reinforce the real-world need.

The advocacy mindset that works

You’re not asking for “extra.” You’re aligning home care hours to actual daily risk and what it takes to remain safely at home-which is the whole point of MLTC. For official program overviews and member pathways, New York State Department of Health provides MLTC resources and complaint/appeal guidance.