In Conversation with Alexey Dmitriyev on Medicaid, EVV & Home Care Ops in 2026

The rules of home care are changing – and in 2026, there’s far less room for error. Medicaid programs are tightening oversight, EVV is no longer just a compliance checkbox, and operations that once “worked well enough” are now being questioned at every level.

Agencies are facing denied claims, reduced hours, and increasing audits; not because demand is falling, but because documentation, coordination, and execution aren’t keeping up. The reality? Growth in home care today isn’t just about getting more clients; it’s about proving, documenting, and justifying every hour of care delivered.

And that’s where most agencies struggle. From misaligned plans of care to gaps in real-time reporting and payer confusion, small operational cracks are now turning into major revenue risks. This write-up breaks down what’s really happening behind the scenes – and what agencies must fix now to stay compliant, protect revenue, and scale with confidence in a more regulated, verification-driven home care landscape.

To shed some light on the same, we interviewed a home care industry expert to bring his perspective on the truth about Medicaid, EVV, and home care ops in 2026.

Let us now delve into what he has to say about the truth about Medicaid, EVV, and home care ops in 2026:

Question 1: Many agencies struggle with Medicaid hour reductions; what’s the most effective appeal strategy you’ve seen actually restore hours?

The appeals that consistently succeed are functionally anchored, not narrative-driven. Key components:

1. Granular ADL/IADL Documentation

• Break tasks into step-level dependencies (e.g., “requires hands-on assist for transfers,” rather than “needs help bathing”).
• Clearly quantify frequency and duration (how many times per day and how long each task takes).

2. Demonstrate Change from Prior Baseline

• Show objective decline or instability (falls, cognitive changes, hospitalizations).
• Use comparative language:  “Previously required supervision → now requires physical assistance.”

3. Alignment with the PCP (Plan of Care)

Before and when changes in condition occur, they must be:

• Clearly documented by the PCP
• ADL/IADL needs should be established at baseline and updated as conditions evolve.
• Supported by objective evidence – Include clinical indicators such as falls, hospitalizations, cognitive decline, or worsening mobility.
• Reflected consistently across all records – PCP notes, agency documentation, and assessments must align
• Accompanied by timely referrals – PT/OT evaluations, specialist consults, or hospital follow-ups should validate the change in condition.
• Updated in the Plan of Care (PCP) – Any functional decline must translate into revised care needs and required service hours.

4. Third-Party Reinforcement

Supporting documentation should include: Physician notes, PT/OT evaluations, and Hospital discharge summaries.

5. Managed Long Term Care (MLTC) Case Manager Communication (Critical but Often Missed)

• Each MLTC member is assigned a case manager who conducts monthly assessments/check-in calls.
• Any change in functional status must be reported immediately (not just at reassessment), including: Decline in ADLs/IADLs, Falls or safety incidents, Cognitive changes, Hospitalizations or ER visits.

Ensure these updates are:

• Documented in the MLTC record – acknowledgement increased of care needs in their notes
• Consistent with PCP and agency documentation

 Why It Matters:

• Successful appeals translate functional limitations into clear medical necessity, supported by consistent documentation across all providers.

• If the MLTC is not informed contemporaneously, they often argue the condition is “unchanged,” which weakens the appeal. Real-time reporting creates a documented timeline of decline, making it much harder to justify reduced hours.

Question 2: How can agencies better support families navigating CDPAP and Medicaid pool trusts without overextending internal staff?

To support families effectively, agencies must understand and clearly communicate the correct sequence of eligibility and enrollment while separating operational responsibilities internally.

1. Clarify the Process Flow for Families

• Pooled Trust (Pre-Medicaid Stage) – Required when an individual has excess income and/or resources. Typically initiated before or during the Medicaid application.
• Medicaid Eligibility – Approval is granted once financial eligibility is established
• Independent Assessment – Determines eligibility for home care services (e.g., NYIA)
• MLTC Enrollment – Select service plan and choose between: CDPAP, Traditional home care

2. Ongoing Pooled Trust Requirements

• Monthly contributions must be deposited consistently
• Annual Medicaid recertification requires trust documentation
• Families often struggle with missed contributions or paperwork, which can disrupt coverage

Where agencies can add value: reminders for renewal deadlines, checklists of required documents, light-touch guidance on submissions

3. Operational Model for Agencies

• Agencies should avoid absorbing this complexity into general staff workflows
• Best practice: create a dedicated intake/navigation team responsible for Medicaid pre-screening, pooled trust education, and application guidance

Why It Matters:

When families misunderstand the process, delays and documentation gaps can disrupt eligibility and care continuity. Structured guidance helps agencies reduce administrative strain while ensuring smoother enrollment and sustained coverage.

Question 3: Where do you see the biggest breakdown between agencies and hospitals or physicians and how can care coordination improve?

The core breakdown stems from a structural disconnect between medical care and home care, reinforced by both HIPAA barriers and misunderstanding of scope.

1. Home Care Sits Outside the Traditional Medical Framework

Home care is often treated as non-clinical support, rather than an extension of care delivery. Due to HIPAA constraints and fragmented systems, critical information is not consistently shared with agencies.

Result: Agencies operate with incomplete clinical context, while providers lack visibility into day-to-day patient realities

2. Misunderstanding of Scope of Practice

Physicians and hospital teams often undervalue home care workers and CDPAP caregivers. There is a perception that they provide only basic assistance, rather than continuous observational insight.

In reality, caregivers are the most consistent point of contact and observe changes in functional status, medication adherence issues, nutrition and food access (shopping, meal prep), behavioral or cognitive changes, and safety risks in the home.

3. Missed “Eyes-on-the-Patient” Intelligence

Real-world data is rarely captured in a structured way and communicated back to physicians. As a result, care decisions are made without incorporating daily living realities, leading to inaccurate care plans, preventable hospitalizations, and poor adherence outcomes.

4. How Care Coordination Can Improve

• Reposition home care as a care partner, not a downstream service
• Establish structured reporting loops from caregivers → agency → physician
• Standardize function-based updates (ADLs/IADLs, adherence, risks)
• Enable HIPAA-compliant information sharing pathways

Bottom line: The breakdown is not just communication; rather, it’s a misalignment in how home care is valued within the care continuum. Closing that gap requires elevating caregiver insights into actionable clinical intelligence.

Question 4: From your experience, what causes the most confusion around insurance claims and benefits in home care cases?

The biggest confusion stems from a lack of clarity across three fundamentally different funding sources, such as Medicare, Medicaid, and private pay (including LTC insurance), each with different rules, timelines, and expectations.

1. Medicare vs. Medicaid – Fundamentally Different Models when obtaining home care services

Medicare (Short-Term, Clinical Focus) coverage typically begins after a hospital or rehab stay, is intermittent and limited (a few visits per week), and is time-bound (ends once the patient stabilizes), requiring a skilled need such as Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), or Skilled Nursing.

Key misconception: Families expect Medicare to cover ongoing daily care but it does not.

Medicaid (Long-Term, Functional Need-Based) is designed for ongoing ADL/IADL support, requires financial eligibility and extended home care needs (120+ days), includes independent assessment (NYIA) and MLTC enrollment, after which patients can receive CDPAP or traditional home care. This is a process-driven system, not immediate coverage.

2. Transition and Timing Gaps

Families don’t understand how to transition from Medicare to Medicaid/MLTC. Medicaid approval and MLTC enrollment take time, leading to coverage gaps and delayed care. A common misconception is that approval under one system carries over to another, but Medicare eligibility does not automatically qualify a patient for Medicaid.

3. Private Pay Layer – Often Overlooked

Life insurance with long-term care (LTC) riders allows early access to death benefits for care, but is often misunderstood in terms of activation, eligibility triggers, and payment structure. Standalone long-term care insurance covers services like home care, assisted living, and nursing care, typically triggered by inability to perform ADLs or cognitive decline, with defined benefit periods.

Key distinction: LTC riders draw from life insurance benefits, while standalone LTC insurance is dedicated solely to care funding.

4. System-Level Confusion and Planning Gaps

Families often delay Medicaid planning assuming Medicare will continue coverage, while agencies receive referrals with unrealistic expectations about services and duration. Each system serves a different purpose: Medicare for short-term skilled care, Medicaid for long-term functional care with structured enrollment, and private pay for flexible funding.
Lack of early planning leads to delays, denials, and gaps in care.

5. Shift from Reactive to Proactive Planning

Most care planning begins only after a crisis, such as hospitalization or functional decline. A better approach is to understand coverage systems in advance, evaluate health risks, and explore Medicaid and private pay options early. Proactive planning improves both care continuity and financial stability

6. Reframing Independence as Interdependence

There is a common belief in maintaining full independence, but in reality, care is interdependent. Reframing care as support rather than loss of independence helps families accept care earlier and focus on maintaining dignity and quality of life.

Question 5: Looking toward 2026, what systemic changes in Medicaid or caregiver advocacy should agencies prepare for now?

Agencies should prepare for a home care system that is becoming increasingly regulated and scrutinized.

1. Shift from Trust-Based to Verification-Driven Models

Over the past 15 years, the rapid expansion of Medicaid home care, including the CDPAP program, has led to the perception of limited oversight. This imbalance has raised concerns around fraud, including inflated hours and services not actually delivered.

In response, state and federal entities are tightening controls, shifting the system toward verification-driven processes

2. Rising Compliance and Documentation Expectations

• Agencies will face stricter eligibility and reassessment standards
• More frequent audits and utilization reviews will become the norm
• There will be a heightened expectation for precise, defensible ADL/IADL documentation

3. Expansion of EVV and MLTC Oversight

The use of EVV and real-time monitoring systems will continue to expand. MLTC oversight will require a clear justification of authorized hours and service delivery.

4. Increasing Rigor in Eligibility Criteria (New York Focus)

MLTC eligibility is becoming more closely tied to defined functional thresholds, such as assistance with multiple ADLs or supervision due to cognitive impairment. Initial assessments and ongoing reassessments will require greater rigor with less tolerance for vague or inconsistent documentation.

5. CDPAP Centralization and System Restructuring

The CDPAP program is moving toward centralization under a single fiscal intermediary. This shift is aimed at reducing costs while strengthening oversight and controls.

6. Opportunity in Underserved and Rural Markets

Rural markets face caregiver shortages, long travel distances, and limited provider networks. 
These challenges create opportunities for agencies to innovate through hybrid care models, remote monitoring, optimized scheduling and routing, AI-driven care coordination and documentation, and structured use of family caregivers under CDPAP.

7. The Future: Outcomes-Driven and Documentation-Led Care

Medicaid home care will become more regulated, monitored, and driven by measurable outcomes and documentation. Agencies that invest in compliance infrastructure, high-quality documentation, and innovative care delivery models will be best positioned to succeed.

Question 6: Do you see AI playing a meaningful role in care coordination or benefit navigation—or is human advocacy still irreplaceable?

AI should play a supportive role in home care, primarily on the backend, while human advocacy remains essential on the front end.

1. AI as a Backend Enabler

AI can reduce administrative burden by structuring and organizing ADL/IADL documentation for assessments and appeals. It can support benefit navigation by identifying eligibility pathways across Medicare, Medicaid, and private pay.

It can flag missing steps in complex processes and streamline care coordination by tracking authorizations, reassessments, and timelines. It can automate reminders for recertifications, trust contributions, and MLTC updates, enabling agencies to scale operations without overextending staff.

2. AI’s Role in Real-Time Care Coordination

AI can facilitate real-time data exchange between home care and clinical settings. Caregiver observations, such as changes in ADLs, medication adherence, nutrition, or behavior, can be structured and transmitted into EHR systems.

This gives physicians access to continuous, real-world insights instead of relying only on episodic visits. The result is more timely decision-making, earlier issue identification, improved adherence, and reduced hospitalizations and ER visits.

This shifts home care from a service provider to a data-driven clinical partner

3. Human Advocacy Remains Irreplaceable

Home care requires human connection, active listening, and the ability to navigate complex, non-standard situations. It involves emotional support, trust-building during critical moments, and effective advocacy in appeals, MLTC discussions, and physician coordination. These are deeply human functions that cannot be automated

4. The Ideal Model: AI + Human-Led Care

AI should remove backend friction and improve information flow. Human-led advocacy should remain the foundation of care delivery.

The most effective model combines AI-enabled coordination with human-centered advocacy, positioning home care as an integrated part of the healthcare ecosystem.

In conclusion

The future of home care isn’t just about adapting; it’s about operating with clarity in a system that no longer tolerates gaps. As Medicaid oversight tightens and EVV becomes central to accountability, agencies must shift from reactive workflows to structured, evidence-driven operations. 

As highlighted throughout this conversation, success will depend on how well agencies document care, coordinate across stakeholders, and align with evolving payer expectations. At the same time, the balance between technology and human advocacy will define outcomes. Those who invest early in compliance, communication, and smarter care delivery models will not only survive these changes but lead the next phase of home care.