ASS1

The Nurse as Advocate

Denise Snow, JD, RN, CNM, NP

Definitions

 DSS- on Long Island, the social agency that provides public assistance (welfare), food stamps, homeless shelters, and of course, Medicaid, is called the Department of Social Services, or DSS.

In NYC, this agency is called Human Resouce Administration, or HRA.

Department of Social Services

(DSS)  Patients may need to apply for Medicaid and other

assistance when they are no longer able to work.

 Often, a spouse will need to stop working to care for the sick spouse.

 The patient should be aware that the process of applying for benefits is time consuming, frustrating and exhausting.

 They can get someone to represent them- they simply need a letter authorizing someone to speak on their behalf.

 If the application for Medicaid is delayed (>45 days) patient should request Fair Hearing

Fair Hearings

 A Fair Hearing is an appeal of a denial made by DSS.

The United States Constitution requires that all persons have “due process” if life, liberty, or property is deprived.

Courts have determined that public assistance is a property and that procedural due process is required before an applicant or recipient is deprived/denied a benefit.

So, the minimum procedural items necessary for due process is 1) Notice 2) a chance to appeal the decision, which is called a Fair Hearing.

Fair Hearing Continued

 Due process applies to every person, including non-citizens (Please read the 14th amendment of the US Constitution)

 However, nurses should know that undocumented persons (aliens) are not able to get these benefits with the exception of food stamps, Health Care for Children until the age of 18 (Child Health Plus) or emergency Medicaid which means Medicaid for life threatening illness.

Nurse’s Role

 Advocate!

If your patient is denied a benefit, you need to be able to tell the patient they can appeal this decision so long as 60 days has not elapsed from the time of the notice of denial.

I always start by looking at the notice. What exactly is the reason for the denial???

Disability

 Short term

 Covered under NYS insurance laws

 Long term disability- insurance companies will deny, deny, deny!

 APRN’s medical records ( progress note, etc.) DOCUMENTS CRITICAL TO ALL of the ABOVE

Permanent Disability

 Application for Social Security Disability/Social Security Insurance

 Standard is if a person is unable to work for 12 months or more because of their illness, they are disabled.

 Disability applications are denied more than 80% percent of the time and must be appealed.

 The appeal is usually scheduled 18 months later for a hearing before an impartial Administrative Law Judge

 Medical record DOCUMENTS CRITICAL to success of application or appeal

Denial of Authorization

 Insurance companies will often deny authorization for medication, diagnostic tests or treatment that a provider has prescribed.

How do you appeal the denial?

Appealing Decision

 A successful appeal of an insurance company denial depends on documentation and a medically sound appeal.

 You can internally appeal- meaning speak to the medical director who made the denial and tell him/her why the treatment is necessary and if still denied an external appeal can be requested.

 Know the appeal process- there is only 45 days from the denial to appeal

 Make sure to provide the documentation on time.

Guardianship

 Wills

 Standby Guardianship

 Should be in place while individual is still competent

 nurse role: determine if person is mentally incompetent and guardianship should begin.

 Good for sixty days, then will go to court to petition for guardianship

 Biological parent can challenge the guardianship

Housing

 Rentals: Fair Housing Act, “Reasonable Accommodation”

 What is “reasonable”? What does a landlord have to do?

 Emergency shelter- how does that affect the treatment plan?

 Hospice- can the patient be evicted from their home while on hospice? ( the answer is yes, the sheriff who evicts tenants will come with a stretcher). Nurses can intervene- let the sheriff know what is going on with the tenant, the severity of the condition.

Future Planning

 Power of attorney- if your patient is in the hospital, it may become necessary for him/her to have someone to do their banking, etc for them. This document can be terminated at any date the patient specifies or if no date is specified, upon the death of the patient

 Will

 Long term care (Medicaid lookback period)

Health Care Proxy

 Of course, the most important document for a patient is a health care proxy.

 The patient chooses who they wish to make health care decisions for them in the event they are incapacitated. It may or may not be a family relation. There is no legal standard for who is legally responsible to make the health care decision for someone. For example, a spouse does not automatically make decisions and therefore, a health care proxy document must be in place.

 The document terminates when the patient says it does or when the patient dies.