New York’s Medicaid 24-Hour Care Decision: A Mixed Victory for Due Process and Aging in Place

A recent decision from the U.S. Court of Appeals for the Second Circuit in Bellin v. McDonald (decided May 21, 2026) represents both progress and a missed opportunity for New York Medicaid beneficiaries who need intensive in-home care. The court recognized a constitutionally protected property interest in 24-hour personal care services under New York’s Medicaid Managed Long-Term Care (MLTC) program. At the same time, it upheld the state’s existing (and often slow) appeal procedures as constitutionally adequate.

Rosalind Bellin's Plight

At 80 years old and battling multiple serious illnesses, Rosalind Bellin simply wanted to remain safely in her own home. Like thousands of other frail New York seniors, she applied for Medicaid-funded 24-hour in-home personal care services,  the level of round-the-clock support her doctors said she needed to avoid nursing home placement and live with dignity.

Instead, her managed care plan offered her only 8 hours of care each day.

Under New York’s rules, Rosalind had no immediate right to appeal this inadequate offer. She was forced to enroll in the deficient plan first, then formally request more care. Only after that request was denied could she begin the lengthy appeal process.

Frustrated by this bureaucratic maze that left her vulnerable in her own home, Rosalind filed a federal lawsuit against the New York State Department of Health Commissioner. She argued that the state’s restrictive appeals procedures violated her constitutional right to due process.

The district court sided with the state, granting summary judgment and ruling that Rosalind had no protected “property interest” in receiving 24-hour care, meaning she wasn’t even entitled to basic due process protections. Rosalind appealed to the Second Circuit.

Why the Decision Is Positive on Property Interest
The Second Circuit held that qualifying Medicaid recipients have a protected property interest in the specific level of 24-hour at-home personal care services they need. This is significant because a recognized property interest triggers due process protections under the Fourteenth Amendment. Beneficiaries can now argue more forcefully that they are entitled to fair procedures before being denied or under-authorized for the intensive care required to remain safely at home.
This ruling builds on established principles that Medicaid benefits, once granted or legitimately expected, create enforceable interests. It strengthens the position of individuals with high needs who rely on consistent, round-the-clock assistance to avoid nursing home placement.Why It Is Troubling on the Appeal Process
Despite finding a property interest, the court concluded that New York’s current system,  an internal plan appeal followed by a state fair hearing, sufficiently protects that interest. This is troubling for several reasons:

• Delays during appeals can leave vulnerable individuals without adequate care for weeks or months. For someone who truly needs 24-hour support, even a short gap can lead to falls, hospitalization, or forced institutionalization.
• The initial authorization by the MLTC plan is often not immediately appealable in a way that provides swift relief.
• Continuation of benefits (“aid continuing”) is available in many reduction cases but is more limited or unavailable for initial under-authorizations.
• The decision essentially defers to the existing administrative structure rather than requiring faster or more robust procedural safeguards at the front end.

While the court acknowledged the importance of the interest, it did not mandate immediate relief mechanisms that many advocates believe are necessary when someone’s ability to stay at home hangs in the balance.Impact on Aging-in-Place Planning
This decision has direct implications for families committed to aging in place:

• It highlights the fragility of in-home care authorizations. Even with a recognized right, the practical path to enforcing adequate hours can be slow and uncertain.
• Families should plan proactively rather than reactively. Waiting until a crisis forces an MLTC enrollment or hours request increases risk.
• Strong legal documents become even more critical: durable powers of attorney, healthcare proxies, trusts, advanced directives, and clear instructions about preferences for home-based care.
• Advocacy and documentation matter enormously. Detailed medical records, physician letters specifying the exact need for 24-hour care, and timely appeals can make a meaningful difference.

The ruling serves as a reminder that while courts may recognize important rights, the real-world delivery of those rights often depends on robust planning and persistent advocacy long before a denial occurs.Comparison of Appeals Processes: New York, Ohio, and Missouri
The following is a high-level comparison of how appeals work for long-term care/Medicaid services in these three states (focusing on managed care or waiver programs where most home- and community-based services are delivered):
New York (MLTC / Personal Care Services)

• Internal appeal with the managed care plan first (often required).
• Then state fair hearing.
• Aid continuing available in many cases if timely requested.
• Initial authorizations have limited immediate appeal rights (as highlighted in Bellin).
• Process can be multi-layered and time-consuming.

Ohio

• Internal appeal with the managed care plan (MyCare or similar).
• State fair hearing through the Bureau of State Hearings.
• Generally strong continuation-of-benefits rules when services are reduced.
• More straightforward “one-stop” state hearing option in many cases compared to New York’s two-step process.
• Timelines are relatively clear (often 60–90 days to request a hearing).

Missouri

• Administrative review/appeal through the Department of Social Services or Department of Health and Senior Services.
• Fair hearing process available for eligibility and service denials/reductions.
• Continuation of benefits possible during appeal in many long-term care and HCBS waiver cases.
• Generally viewed as somewhat more streamlined than New York’s layered MLTC system, though still administrative in nature.
• Specific rules apply for nursing facility discharges and HCBS waivers.

Key Takeaways Across States

• All three states offer some form of fair hearing, consistent with federal Medicaid requirements.
• New York’s managed care system adds an extra internal appeal layer that can extend timelines.
• Ohio and Missouri tend to have somewhat more direct paths to a state-level hearing.
• Continuation of benefits during appeal is a critical protection in all three, but availability and ease of obtaining it vary.
• None of the states currently provides an automatic “immediate” appeal right for initial service authorizations in the same way some advocates would prefer.

Bottom Line for Families
The Bellin decision is a partial win: it affirms that people have a real stake in the care they need to stay at home. However, it also underscores that rights on paper do not always translate to timely help in practice.
The most effective strategy for aging in place remains proactive planning, combining legal tools, clear documentation of care needs, strong powers of attorney, trusts, advance directives, and early engagement with knowledgeable elder law counsel, rather than relying solely on the appeals process after a denial occurs.
If you or a loved one are facing challenges with Medicaid long-term care services in New York, Ohio, or Missouri, consult an experienced elder law attorney in your state promptly. Early planning and proper advocacy can make all the difference between remaining at home and facing unnecessary institutionalization.