If the current hours no longer cover real life, you’re allowed to ask for more. This guide shows New York families how to document changing needs, request a reassessment, and, if needed, appeal a decision so hours match what’s happening at home.

When to Ask for More Hours

Request a reassessment as soon as any of these occur:

• New safety risks: falls, near-falls, wandering, confusion at night
  
• Nighttime needs: frequent toileting, insomnia, sundowning, hands-on transfers
  
• Clinical changes: new diagnosis, wounds, infection, oxygen, mobility decline
  
• Hospital/rehab discharge: care is more complex than before
  
• Caregiver limits: primary caregiver illness, work change, or burnout

Rule of thumb: if you’re routinely “stretching” beyond approved hours to keep someone safe, it’s time to ask.

What Plans Look For (and How to Show It)

Plans authorize hours based on measurable need, not effort or love. Focus your case on:

• ADLs (activities of daily living): bathing, dressing, toileting, eating, transferring, mobility
  
• IADLs (instrumental tasks tied to care): meal prep, laundry, light cleaning, shopping
  
• Supervision for safety: cueing, redirection, wandering prevention, fall risk
  
• Overnight care: hands-on help between 10pm–6am or the need for an awake-overnight aide

Make it real: “3 nighttime toileting assists with hands-on help to and from the bathroom, plus bedding changes 2 nights/week” is stronger than “needs more help at night.”

Build a “Change in Condition” Packet (Before You Call)

Gather everything that proves the increase:

• Incident log (2–4 weeks): dates/times of falls, nighttime assists, wandering, agitation
  
• Hospital/rehab paperwork: discharge summary, after-visit instructions
  
• Doctor’s notes: new orders, wound care, weight loss, mobility changes
  
• Medication list: recent additions (e.g., diuretics → more bathroom trips)
  
• Photos (optional): home setup hazards you’re mitigating daily
  
• Caregiver statement: 1 page, bullet points with frequency/unsafe scenarios
  
• If CDPAP: timesheets showing consistent overages/near-misses, backup caregiver fatigue

Keep copies, you’ll use this packet again for appeals if needed.

Step-by-Step: Requesting a Reassessment in New York

1) Call Your Plan

Ask Member Services for a home care reassessment due to a change in condition.

• Confirm the earliest assessment date.
  
• Ask where to send supporting documents and whether you can provide them before the visit.

2) Prepare for the Nurse Visit

• Post your med list and daily schedule where they’re easy to review.
  
• Have your packet on the table.
  
• Ensure the person who knows the routine best is present (or a Designated Representative).
  
• Show the hard moments: don’t “power through” as usual, demonstrate what typical help looks like.

3) Be Specific During the Assessment

Use concrete statements:

• “Transfers require two-person assist after 6pm.”
  
• “Three bathroom trips between midnight and 5am with hands-on help.”
  
• “Wanders to the door four nights/week; alarms in place.”
  
• “Needs cueing to eat and take meds; otherwise refuses.”
  

4) Get the Decision

You’ll receive a Notice of Action/Determination (approval, partial approval, or denial). Keep it, deadlines live here.

If You Don’t Get Enough Hours: Appeal Path

You have rights. Use them in order and on time:

1. Plan Appeal (Internal Appeal)
   
   • File promptly (use the deadline on your notice).
     
   • Submit your packet again with a short cover letter explaining exactly which hours/periods are unsafe or unmet.
     
2. Fair Hearing (State Hearing)
   
   • If you disagree with the appeal decision, request a hearing by the deadline on your notice.
     

Aid Continuing (keeping current hours during an appeal):
Ask for it by the date listed on your notice (often within a short window). If granted, previously authorized hours continue while the appeal is pending. If the final outcome doesn’t go your way, plans may recover the value of continued services, ask your plan to explain implications.

Tip: When you appeal, add fresh evidence, a new incident log, updated doctor notes, or post-discharge instructions.

For CDPAP Users (Same Rules, Different Staffing)

• Authorization drives hours the same way it does for agency aides.
  
• Your caregiver can be a family member/friend (spouse/parent of a minor are typically excluded).
  
• Keep EVV/time data and a simple night log, they’re powerful evidence for more hours.

Common Mistakes (Easy to Avoid)

• Waiting months before requesting reassessment
  
• Minimizing struggles (“We manage somehow”) instead of describing risks
  
• Vague language (“more help”) vs. measurable need (“2-person assist, 3x nightly”)
  
• Missing deadlines on the notice
  
• No backup plan if Aid Continuing isn’t granted, line up short-term respite or private coverage for gaps

Day-Of-Assessment Checklist

• Med list and recent hospital/rehab paperwork ready
  
• Incident/night log printed (2–4 weeks)
  
• Change in condition cover sheet (1 page)
  
• Primary caregiver/DR present for the visit
  
• Home setup visible (commode, grab bars, walker, alarms)
  
• Demonstrate actual assistance, not the “best day” version

After You Win More Hours, Make Them Work

• Schedule peak-need coverage first (mornings/evenings, nights).
  
• Blend supports: agency or CDPAP + adult day to reduce unsafe gaps.
  
• Reassess every 30–60 days; if nights worsen, repeat this process quickly.

How Individual Home Care Helps

• Evidence builder: We turn your daily reality into a clean, persuasive packet (logs, notes, risks).
  
• Assessment coaching: Exactly what to say, and show, so needs are clear.
  
• Appeal support: Organize documents, draft cover notes, track deadlines.
  
• Care plan fit: Translate new hours into a safer weekly schedule (and line up backup coverage).

Note: Educational resource only; not legal advice or a clinical directive. Confirm current program rules and deadlines on your plan notices.