Challenges With Accessing Home Care Among Medicaid Beneficiaries.

Importance: Many older adults with chronic conditions require formal care at home to age in place. However, obtaining such care can be challenging and costly, even with insurance coverage. Objective: To assess the availability of and access to home care services among Medicaid recipients in the state of New York. Design, Setting, and Participants: This cross-sectional secret shopper study was conducted between February and May 2024 in a random sample of licensed home care service agencies (LHCSAs) in New York. Trained author investigators posed as caregivers seeking home care services for a 70-year-old family member with Medicaid insurance. Exposure: Telephone call requesting home care for an older adult with chronic conditions and functional limitations at home. Main Outcomes and Measures: Outcomes were availability of home care services, acceptance of Medicaid, time to evaluation and start of services, anticipated hours of (covered) care, and cost per hour for additional services. Quantitative and qualitative data were collected during telephone calls. Results: Among the 331 LHCSAs selected for outreach, 169 were successfully contacted (51.1% response rate); among those, 125 (74.0%) accepted Medicaid. While most LHCSAs (141 [83.4%]) reported the ability to start care after completing the required eligibility evaluation, long wait times (>1 week) for those evaluations, which were required to start care, were common (75 LHCSAs [44.4%]). Estimating hours of service that could be granted was difficult for LHCSA representatives, with 135 (79.9%) unable or declining to provide an estimate. Among the 34 (20.1%) who did, most (25 [73.5%]) estimated they could provide from 10 up to 30 hours per week. The mean (SD) cost per hour among LHCSAs for additional services beyond the insurance-approved amount was $33.35 ($5.05). Key themes from telephone conversations were complexity of the Medicaid home care process, challenges in obtaining sufficient hours, use of private pay to supplement care, workforce-related factors affecting access, and variability in LHCSA knowledge and accessibility of care. Conclusions and Relevance: In this cross-sectional study of LHCSAs in New York, obtaining care at home involved a complex, multistep process with potential barriers to access, even for individuals with Medicaid coverage. The findings suggest family caregivers and patients may face long wait times, unpredictable coverage determinations, staffing shortages, and high out-of-pocket costs for additional hours, highlighting the need for streamlined processes, greater transparency, and stronger workforce support to ensure equitable access to home care.