When a Client's Hours Aren't Enough: Can You Appeal for More, or Move Them to a Different Waiver?
You’ve had this conversation before. A family calls because they’re worried their loved one needs more care than the authorized hours will cover. Lately, that conversation has become even harder. Since the Managed Care Entities took over PathWays, authorizations often take longer, care coordinators change without much notice, and it’s not always clear who to call or what options are available anymore. For agencies trying to help families navigate the system, that uncertainty can make an already difficult conversation even more frustrating.
The good news is that families and agencies do have real options. You just need to know which one applies and how to navigate the process.
Before we dive in, one quick note: this post is general educational information for Indiana home care and home health agencies. It isn’t legal advice. Appeal rights, deadlines, and processes vary by waiver, by MCE, and by the specific notice a client receives. Treat this as a starting point, not the final word. When things get complicated, involve the client’s case manager, MCE care coordinator, or an elder law or legal aid attorney.
First, figure out which program you’re actually dealing with
Indiana doesn’t have just one waiver program. It has several, and the path forward depends on which one your client is enrolled in.
- PathWays for Aging (age 60+): Managed care through one of three MCEs — Anthem, Humana, or UnitedHealthcare. The MCE develops the Plan of Care and issues the Notice of Action.
- Health & Wellness Waiver (under age 60, nursing facility level of care): Fee-for-service program managed by IHCP with care plans managed through a case manager.
- CIH, Family Supports, and TBI Waivers: Fee-for-service programs for individuals with intellectual or developmental disabilities or a traumatic brain injury who meet the applicable level of care.
Each of these programs follows its own process. Appealing an MCE decision under PathWays looks different than appealing a fee-for-service denial on the Health & Wellness Waiver. And with level of care assessments statewide transitioning to the new interRAI assessment tool, even the way need is documented is changing. Before moving forward, it’s worth confirming which rules apply to your client’s specific situation.
Yes, you can appeal for more hours. Here’s how it actually works.
Authorized hours are based on a documented level of need that’s outlined in the client’s Plan of Care or service plan following an assessment. If a family believes those hours no longer reflect what their loved one actually needs, there are two ways to approach it.
Ask for a reassessment proactively
In many cases, this is the faster and easier option.
A case manager (for fee-for-service waivers) or an MCE care coordinator (for PathWays) can request an updated assessment whenever there’s a legitimate, documented change in condition. That might include a hospitalization, a new diagnosis, an increased fall risk, or the loss of an informal caregiver. The more specific and clinical the documentation, the stronger the request is likely to be.
Simply saying, “the family wants more help,” probably won’t move the process forward very quickly. Explaining that “the client fell twice last month and can no longer transfer independently” paints a much clearer clinical picture of why additional hours may be necessary.
Appeal if hours are denied or reduced
If a request for additional hours is denied, or if existing hours are reduced, the client receives a formal notice — like an Adverse Benefit Determination or Notice of Action — that explains the decision and outlines the client’s appeal rights.
Broadly speaking:
- Appeals generally must be filed in writing by the deadline printed on the notice. Depending on the situation, that deadline may be as short as 10 days (to keep services in place while the appeal is pending) or as long as 60 or even 120 days for a standard appeal. Always rely on the timeline printed on the actual notice.
- If the appeal involves a service the client is already receiving and it’s filed within the required timeframe, the client may be able to continue receiving that service while the appeal is being decided.
- If an MCE upholds its original denial, the member can request a State Fair Hearing before an administrative law judge through Indiana’s Office of Administrative Law Proceedings.
- The client or family can represent themselves at the hearing or bring an attorney, family member, or advocate. There is no cost to file.
One of the biggest mistakes agencies see is surprisingly simple: someone doesn’t read the notice carefully enough, and the deadline passes. Make it a habit to review these notices as soon as they arrive, not a week before the appeal window closes. Missing the filing deadline can eliminate options that otherwise would have been available.
Can a client move to a different waiver?
Sometimes, but not simply because they request it.
This is where expectations can easily get out of sync. Families understandably hope there’s another waiver that offers more hours, and agencies can unintentionally reinforce that idea. The reality is that waivers aren’t interchangeable. Each one serves a specific population and has its own eligibility and level of care requirements.
- PathWays is designed for individuals age 60 and older.
- Health & Wellness serves adults under age 60 who meet nursing facility level of care.
- CIH and Family Supports serve individuals with intellectual or developmental disabilities who meet an ICF/IID level of care.
- TBI serves individuals with a qualifying traumatic brain injury.
A client may transition to a different waiver when their circumstances genuinely change and they now meet another program’s eligibility requirements. That could mean aging into PathWays or experiencing a new diagnosis or functional decline that qualifies them for a different waiver.
Those situations must be evaluated through the appropriate organization, whether that’s the Area Agency on Aging, the client’s case manager, or the Bureau of Disabilities Services, depending on the waiver involved. Most importantly, the transition has to reflect where the client actually belongs.
Trying to pursue a waiver that doesn’t match the client’s true circumstances can create problems during future level of care reviews or audits. That’s why these conversations should happen openly, with the client’s case manager involved from the beginning. Having everyone on the same page early often leads to better outcomes than trying to force a client into a program they don’t actually qualify for.
Where agencies often find more flexibility is within the waiver the client already has. Self-direction, for example, allows families to have greater control over who provides care and how authorized hours are used, even though it doesn’t increase the total number of hours available.
It’s harder right now, and you’re not imagining it.
Since PathWays transitioned to managed care, agencies across Indiana have felt the impact. Authorizations take longer. Documentation requirements have increased. Care coordinators don’t always have the full picture. Providers across the state have reported these challenges, and they’re not likely to disappear overnight.
While agencies can’t control those system-wide challenges, they can control what happens after care is delivered. Making sure every authorized hour gets billed correctly and paid is more important than ever. When authorizations are harder to obtain and reassessments take longer, the hours you already have approved become even more valuable.
That’s also where many agencies quietly lose revenue — not because the care wasn’t provided, but because the claim never made it across the finish line. Small billing issues, missed follow-up, or unnoticed denials can add up quickly, especially when margins are already tight.
If your team is spending more time chasing authorizations than collecting payment for the care you’re already providing, it may be worth talking with GEOH’s billing team. We’ll help make sure you’re getting every dollar you’ve earned.
Final Thoughts
Have a question about a specific client’s situation?
This post is meant to help you understand the general process, not resolve an individual case. For anything client-specific — especially appeals, level of care disputes, or potential waiver transitions — work directly with the client’s case manager or MCE care coordinator, and consider involving an elder law or disability rights attorney when the situation calls for it.
Understanding the options available can help agencies better support the families they serve, even when the answer isn’t as simple as requesting more hours. Knowing when to request a reassessment, when to file an appeal, and when a different waiver may truly be appropriate can make a meaningful difference for both clients and caregivers.