Becky, a 46-year-old woman from Berks County, contacted PHLP for help when she could not get the personal assistance service hours she needed from her Community HealthChoices (CHC) Managed Care Organization (MCO). Becky, who has multiple sclerosis, is almost completely immobilized and as a result is totally dependent on the assistance of others. When she contacted PHLP, she was also recovering from surgery on a serious wound and needed to be repositioned every 1-2 hours throughout the day and night so as not to worsen the wound or get any new ones. Becky’s case was complicated by the fact that she had transitioned to the CHC waiver in January 2020 but wasn’t assigned a service coordinator until more than two months later. As a result, her family had no one to reach out to for help when a temporary authorization for 22 hours per day of care lapsed, leaving her with only 14 hours per day of personal assistance services. Becky’s husband works full time and needed to sleep and be present for the couple’s teenaged daughter when he was not working, so he wasn’t available as a regular caregiver. Without the hours Becky needed from her health plan, her 73-year-old mother was exhausting herself coming in to care for Becky 10 hours a day, 7 days a week.
PHLP represented Becky at a grievance against the CHC MCO and helped Becky and her family present her case for more in-home care. The family explained that Becky needed additional hours so she could recover from her wound, get out of bed, return to physical therapy and occupational therapy, and get some quality of life back. Becky has a customized wheelchair – before her wound she was able to be in her wheelchair several hours a day, interacting with her family and eating upright – but she couldn’t get back into it until her wound healed. After hearing Becky and her family’s presentation, the medical director who heard the case stated that there was no clinical argument against providing her the hours that she needed and approved the additional hours of care immediately.