Nys Medicaid Home Care Eligibility


When Medicaid Covers Assisted Living Facilities For New Yorkers

Gov. Cuomo proposes to cut $75 million from CDPAP Medicaid program

An assisted living facility provides room and board, therapy and nursing services, and supervision. ALFs are generally less expensive and less medically intensive than a nursing home. Some ALFs are specially licensed by the state to accept Medicaid residents, and those are known as Assisted Living Programs . You can find an ALP near you here.

None of the managed long-term care programs in New York will cover assisted living facility fees.

If you are a New York resident and you want Medicaid to cover your stay in an assisted living facility, then you must qualify for ALP. ALP has limited enrollment, so it is not available to everyone who wants it.

To qualify for ALP, you must need the nursing home level of care. Furthermore, you must show that, but for the ALP, you would have to be placed in a nursing home because you do not have a home or a suitable home environment. At the same time, you cannot require 24-hour nursing care, be bedridden, or be a danger to other ALP residents. ALP has a higher income limit than regular Medicaid you must have a monthly income lower than $1,441 in 2018 to qualify for an Assisted Living Program.

Most assisted living facilities are not licensed to be ALPs, and they generally accept only private pay residents. However, residents in ALFs can qualify for Medicaid home health services that can be provided to them while they live in the ALF.

What Are Personal Care Services

Personal care services are assistance of a personal care aide with nutritional, environmental support, and personal care functions. “Such services must be essential to the maintenance of the patients health and safety in his or her own home” ordered by the attending physician based on an assessment of the patients needs and of the appropriateness and cost-effectiveness” of services. 18 NYCRR 505.14.

There are two “levels” or types of PCS in New York State.

  • HOUSEKEEPING or “Level 1” – for those who because of disability need assistance with housekeeping, cleaning, meal preparation, grocery shopping, and laundry, but they do not need help with “personal care” tasks such as bathing or dressing. These services are limited by state law to EIGHT hours per week. 18 NYCRR 505.14. NOTE – Adults who have Medicare, who would otherwise be required to enroll in an Managed Long Term Care plan, but who only need Housekeeping services may NOT enroll in MLTC. They obtain these Housekeeping services by applying at the local district/ HRA.

  • PERSONAL CARE or “Level 2” — includes all of the Housekeeping tasks PLUS assistance with personal needs – bathing, dressing, grooming, toileting, walking, feeding, assisting with administering medications, preparing meals with special diets, and routine skin care. In amendments in December 2015, “turning and positioning” was specifically added as a task, as needed by bedbound individuals who cannot turn themselves, putting them at risk of bed sores.

  • Do I Need To Be In A Medicaid Managed Care Plan To Enroll In The Cdpap Program

    Most consumers must be enrolled in some form of Medicaid Managed Care to enroll. The good news is, you may have a choice as to what type of plan you enroll in. If you will be enrolling in Managed Long-Term Care , as many consumers must, there are a few different types of MLTC plans to choose from, each offering the consumer their own unique set of benefits. To learn more about the different types of plans, see Managed Long-Term Care Plans.

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    Income Rules For Home Health Care Medicaid Coverage

    For 2022, a single person is entitled to keep $954 of his/her monthly income. The healthy spouse is entitled to keep at least $3,435 of the couples combined income. If the healthy spouse has income of his/her own above $3,435, then the Medicaid Agency will request a contribution of 25% of all income above $3,435.

    We Also Encourage You To Download Our Take On Obtaining Medicaid For Home Care:

    Medicaid Eligibility Income Chart 2019 Ny  cptcode.se

    Please Note: Information provided herein is for convenience purposes. Nothing on this page or website constitutes legal advice, and we recommend that you verify all information on your own and seek legal counsel where appropriate. Please see full disclaimer at the bottom of this page.

    When it comes to Medicaid in NY State, the first thing that one needs to determine is the applicants budgeting category. People in different age groups and circumstances are subject to different eligibility rules, and the services available in each category may also vary. In this section we will be discussing eligibility and services for the aged, blind, and disabled. This category includes people who are 65 and above, certified blind by the Commission for the Blind and Visually Handicapped, and certified disabled by Social Security or NY State . There are three levels of Medicaid for this category:

    • Community Medicaid
    Get help applying for Medicaid for home care
    What is Covered by Community Medicaid?

    While Medicaid covers prescription drugs, people with Medicare will not have their prescription drugs paid for by Medicaid directly. Rather, Medicaid will pay Medicare to provide a free Medicare Part D prescription drug plan for these beneficiaries. Click here to learn more about this.

    Community Medicaid with Long-Term Care provides everything that Community Medicaid does with the addition of community based long-term care services such as home care, adult day care, and assisted living .

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    Medicaid Eligibility For Nursing Home Care

    In order to qualify for Medicaid, your life savings cannot be greater than the Medicaid resource limit. Certain assets are not counted as being part of your life savings. For example, if you have a spouse living in the family home, then the home does not count for Medicaid resource limit purposes.

    If your life savings is higher than the Medicaid limit, you will not be eligible to receive Medicaid coverage for your nursing home or home care costs. You will be told to spend your life savings towards your cost of care until you are down to the Medicaid levels.

    You should never assume that it is too late. Quite often you have legal options to save some or all of your life savings even if you are already in a nursing home. The Koldin Law Center, P.C. Medicaid Law Attorneys can represent you throughout the entire Medicaid process. There is something you can do.

    There are many special exceptions to the basic Medicaid rules where additional assets can be protected.

    Where Can I Get A Cdpap Application

    If you want to apply for CDPAP and youre trying to figure out where to start, please know that there are often several steps involved in the application process, and it is not just a matter of filling out a single application form . We break down the process into three components:

    1. Assessment Most CDPAP applicants must be assessed by a nurse before enrolling.

    2. Consumer Forms Certain forms are required. See CDPAP Forms for more.

    3. Select your caregiver of choice.

    Concerned about all the details? The good news is, were here to help you every step of the way. So dont break a sweat trying to decipher all the different parts of the enrollment process. Give us a call and let one of our specialists explain the entire application process and guide you through your enrollment.

    Please Note: Edison Home Health Care is a Fiscal Intermediary for CDPAP. We do not administer the program. We can help you navigate, but application and enrollment for CDPAP must go through your Local Department of Social Services or Medicaid plan.

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    New York State Budget Expands Medicaid Eligibility For Older Adults

    Reaction to the 2023 New York State budget continues, and older adult advocates are pleased that the $220 billion plan passed by lawmakers earlier this month expands Medicaid eligibility.

    Starting in 2023, older, disabled and blind New Yorkers can make up to 138% of the federal poverty level and still qualify for taxpayer-funded health care coverage. That would increase the maximum monthly income for those groups from $934 a month to $1,563 a month.

    So what this is going to do is massively expand the reach of the Medicaid program for folks, specifically in the age, blind and disabled categories of eligibility, said attorney Kelly Barrett Sarama with the Center for Elder Law and Justice, a Buffalo nonprofit legal agency.

    In addition, the maximum assets those groups can have and still qualify for Medicaid will nearly double, from $16,800 to $28,134. For couples, the allowable maximum assets will increase from $24,600 to $37,908.

    Under the current limits, Sarama said many people have to spend down much of their assets in order to qualify for Medicaid. Plus, she said, many younger Medicaid recipients, who are not subject to an asset test, lose their coverage once they move into the older, disabled or blind categories.

    The budget also makes Medicaid available to undocumnted immigrants 65 and older, as well as extends postpartum coverage for Medicaid-eligible mothers from 60 days after they give birth to one year after they give birth.

    Does Medicare Cover Cdpap

    Months after Medicaid transition, some providers still wait for payment

    Medicare does not cover CDPAP. CDPAP is a Medicaid based program, and you must have Medicaid to enroll. Many consumers have both Medicare and Medicaid. Those consumers can enroll because their Medicaid will provide coverage. If you only have Medicare and do not have Medicaid, we may still be able to help. We have Medicaid specialists that can guide you through the process of applying for Medicaid.

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    What Is Medicaid In New York

    Medicaid provides payment for institutional and community-based care for eligible persons who are treated by participating institutions and practitioners. Medicaid covers nursing home care and all other medical care including home care, acute hospital care, physicians and pharmacy.

    When is a person over age 65 eligible to receive Medicaid?

    Medicaid is a means-tested, needs-based program with limitations on income and resources. Anyone who meets the income and resource limitations is eligible to receive Medicaid.

    Availability of income/resources : What are the current asset and income levels that allow Medicaid eligibility?

    INCOME:Income is broadly interpreted, and includes earned and unearned income and most government benefits.

    The current monthly income limit for a family of one seeking community based Medicaid is $934.

    The current monthly income limit for a spouse of an applicant seeking coverage for nursing home care is $3,435 plus 75% of the excess.

    The current monthly income limit for the nursing home applicant is $50.

    RESOURCES: The resource or asset limit for a family of one seeking community based Medicaid is $16,800 plus $1,500 in a separate burial account.

    The spouse of an applicant seeking coverage for nursing home care is allowed between $74,820 and $137,400 in resources, plus $1,500 in a burial account.

    Income and resource levels are subject to yearly adjustments.

    What resources are not counted when determining Medicaid eligibility?

    What is spending down?

    New York Medicaid Guide

    *Updated for 2022

    No longer being able to offer care to a loved one is tough situation that many must face. If you or a loved one is about to enter a nursing home or need assistance with Medicaid, the New York Medicaid Guide created by our Buffalo Elder Law Attorneys will help you manage your loved ones future.

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    Managed Long Term Care Plans

    Managed Long Term Care plans are insurance plans to which NY Medicaid pays a monthly premium in exchange for approving applicants for community-based care and providing associated services.

    In order to be enrolled in an MLTC plan and obtain Medicaid home care services, you must first qualify for Medicaid based on current income guidelines. If you dont qualify, you may be able to utilize Medicaids spend-down program to reduce income or assets in excess of the limits. In some cases, excessive assets may be deemed exempt from the calculations, or non-exempt assets may be transferred out of your name in order to qualify.

    However, the ability to transfer assets in order to immediately qualify for home care benefits is quickly coming to an end. An experienced Medicaid planning lawyer can review your finances to determine if you qualify and how to proceed.

    How Does One Obtain Personal Care Services

    New York and the ACAs Medicaid expansion

    First, one must apply for and become eligible for Community Medicaid, Those under 65 and not on Medicare apply for Medicaid on the NYS of Health Exchange, and those 65+ or who have Medicare apply through their local Medicaid office. See this article for where to apply in New York City. See info about Medicaid applications.

    Second, how a Medicaid recipient accesses Personal Care services depends on their age, whether they have Medicare, and some other factors.

  • Under 65 and not on Medicare – Most people in this category are automatically assigned to a “mainstream Medicaid managed care plan” when Medicaid is approved. Since August 2011, members of these plans must request Personal Care – including Housekeeping Level I and Personal Care Level II, Consumer-Directed Personal Assistance, private duty nursing, and other home care services through these plans. The plans assess the need for services, contract with home care agencies, and authorize services. The State Department of Health has issued guidelines that include instructions on how consumers should request PCA services from their plans.NYSDOH Guidelines to Personal Care Services in Medicaid Managed Care.

  • Medicare beneficiaries age 21+ who are not in hospice or OPWDD waiver – most must first request a Conflict-Free Eligibility assessment from NY Medicaid Choice, and then enroll in a Managed Long Term Care plan in order to obtain PCA or CDPAP services. See some exceptions here.
  • Those who do not have Medicare may apply if:
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    Medicaid Covered Home Care

    There have been major changes made to the Medicaid Home Care program in 2013 and 2014. Medicaid covered home care is often overlooked as an alternative to Nursing Home placement.

    In the past, there were two major disadvantages to Medicaid covered home care. First, the amount of care provided at home was often insufficient and second, the healthy spouse was often allowed to keep more income and life savings if the ill spouse were placed in a Nursing Home.

    Eligibility for Medicaid must be established before coverage will be provided. Without proper legal advice, Medicaid requires that you privately pay for your own health care until your life savings is depleted.

    Under the changes made in 2013 and 2014, home care has become a more realistic option. The healthy spouse is now entitled to keep the same amount of income and resources that he/she would be able to keep if the ill spouse is at home or at a Nursing Home. There is no longer a major financial incentive for the healthy spouse to place the ill spouse in a Nursing Home.

    There is a serious lack of information and procedures by the counties to implement managed home care. As a result, each home care case can be treated differently by each county until this program becomes more established. The procedures for being medically evaluated and applying for Medicaid coverage are still not totally clear and appear to be constantly changing.

    There are now 2 main Medicaid covered home care programs for the elderly:

    Will The State Take My Home If I Need Medicaid To Pay For My Care In New York

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    Not if you have done asset preservation planning. The state never takes your home. However, ownership without proper planning may result in a forced sale if Medicaid demands reimbursement after death. Medicaid may also impose a lien during your lifetime if it is paying for nursing home care. Fortunately, these scenarios are avoidable by undertaking asset protection planning with a reputable elder law attorney. Elder law attorneys are best suited to establish viable long-term health care plans and achieve Medicaid eligibility while preserving assets for the benefit of the applicant or his or her heirs.

    Unless you have purchased a long-term care policy, the only health care insurance that pays for long-term care is Medicaid. In New York, an applicant for Medicaid cannot own more than approximately $16,000 in assets. While the Medicaid recipient is living in his or her home, it will be exempt. This is known as Community Medicaid, where aides are provided at no cost to the applicant. However, if the home remains in the name of the patient, Medicaid will seek to recover after death. Elder law attorneys can discuss strategies, such as the use of a trust, to avoid such an outcome. New Yorks Community Medicaid eligibility rules are set to change April 1, 2021. The advance notice of these changes is affording clients an opportunity to employ strategies that will no longer be available after April.

    Also Check: How To Become A Medicaid Consultant

    Contact Lissner & Lissner Llp Today

    If you are concerned about how the new Medicaid legislation will affect you or a loved one, the skilled legal team at Lissner & Lissner LLP can help. With more than five decades of experience, we have the skill, knowledge, and compassion to help our clients navigate the most complex issues surrounding aging, disability, and illness.

    The increased restrictions affecting Medicaids home care services in New York is going to negatively impact thousands of Medicaid recipients throughout the state. But you may be able to avoid some of the extra headache and expense with proper estate planning. Time is of the essence.

    Contact Lissner & Lissner LLP Today at for a confidential consultation about your case.

    How To Apply For Medicaid Long Term Care Eligibility:

    Are We Still Shunning Medicaid Patients | Morning Report

    The application process begins by calling 858-1901 to request an Access NY application. The date that a completed application is received by this agency is considered to be the application date.

    When completing and returning the Access NY application for Long Term Care, please be sure to complete the Access NY Supplement A form and a notarized authorization to represent. Also include your choice of how we should contact you. Be sure to sign the application AND Supplement A.

    Upon receipt of the completed Access NY application by our agency, the application will be assigned to an examiner who will contact you to discuss the application or arrange a face to face appointment. Face to face meetings are scheduled within two weeks of the agencys receipt of your application. Meetings are scheduled between 8:00 a.m. and 2:00 p.m. at the Rath Building, 158 Pearl Street, Buffalo, NY 14202.

    In addition to verification of gross monthly income and outstanding medical bills, the representative must supply the last 60 months of financial records. This may include all pages of bank statements and statements from brokerage houses. You will need to provide photocopies for us to retain in our records. We require documentation of the source of all deposits and withdrawals of $2,000 or more.

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