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Medicaid is a crucial health care program catering to individuals of all ages with low income. This article delves into the specifics of long-term care Medicaid for elderly residents of New York, those aged 65 and above. Understanding these options is essential for seniors seeking assistance through Medicaid for nursing home care or non-medical services to maintain their independence at home or in community settings. Types of Medicaid Long-Term Care Programs in New YorkInstitutional/Nursing Home MedicaidThe instittutional/nursing home medicaid program is an entitlement, meaning that once you meet the medicaid elligibility requirements, you are guaranteed assistance. The institutional or nursing home medicaid program provides care exclusively in nursing homes. Medicaid Waivers/Home and Community-Based Services (HCBS)Unlike the nursing home program, home and community-based services are not an entitlement. The program has limited slots and potential waiting lists. The community-based services programs aims to delay or avoid nursing home admission by offering services at home, a loved one's home, adult day care, or assisted living facilities. Regular Medicaid/Disabled, Aged 65+ or Blind (DAB)Also an entitlement program, regualar medicaid supports various long-term care services like personal care assistance and adult day care. Specific Medicaid Programs for Elderly Residents in New YorkIn addition to general long-term care coverage, New York offers several Medicaid programs tailored to meet the diverse needs of its elderly population. These programs facilitate living at home or in community settings rather than institutional care, highlighting the state's commitment to maintaining senior independence and quality of life. New York Managed Long-Term Care (MLTC) Program WaiverDesigned for seniors who need nursing facility-level care but prefer to remain in their home or an assisted living environment, New York's Managed Long-Term Care program includes services like personal care assistance, meal delivery, and home modifications. It features a consumer-directed option called the Consumer Directed Personal Assistance Program (CDPAP), which allows participants to select their own care assistants, including certain family members. New York Community First Choice Option (CFCO)The New York Community First Choice option provides home and community-based services under the state Medicaid plan to help seniors manage daily living activities. It supports services such as home health aides and assistive technologies. CFCO participants may also use the CDPAP model for more personalized care. New York Assisted Living Program (ALP)New York's Assisted Living Program funds services in adult care facilities for those seniors who need a nursing home level of care but prefer a less institutional setting. Covered services include skilled nursing, personal care, and emergency response systems. Nursing Home Transition and Diversion (NHTD) WaiverThe Nursing Home Transition and Diversion waiver aids nursing home residents in transitioning to a home setting or to the home of a family member, promoting continued independence and engagement with the community. State Plan Personal Care Services ProgramThe State Plan Peronal Care Services Program provides comprehensive personal care services under the state plan, helping seniors manage their daily needs and maintain their independence. Program of All-Inclusive Care for the Elderly (PACE)the Program of All-Inclusive Care for the Elderly (PACE) is a unique program that combines Medicaid and Medicare benefits into a single plan to cover all required medical and long-term care services, plus additional benefits such as dental and eye care. Money Follows the Person (MFP) - Open DoorsThis federal initiative supports institutionalized individuals who are Medicaid-eligible in transitioning back to community settings, emphasizing a return to normalcy and community life. Navigating Eligibility: Income and Asset LimitsEach Medicaid long-term care category has specific functional and financial requirements, which are annually updated and vary by marital status. New York offers alternative paths to eligibility, which can sometimes seem complex due to these variations. Eligibility Criteria for a Single Nursing Home Applicant (2024):
The chart below shows the Eligibility criteria for single and married applicants.
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Income Considerations
Income sources typically counted towards Medicaid's limit include wages, pensions, and Social Security benefits, among others. Notably, certain sources like Holocaust restitution payments and VA Aid and Attendance benefits do not count as income in New York.
Asset Rules
Countable Assets: These include liquid assets like cash and stocks, and potentially a vacation home.
Non-Countable Assets: Exemptions include one's primary residence, personal belongings, and certain types of burial funds and insurance policies.
Treatment of Assets and Income for Couples
When applying for Medicaid, the non-applicant spouse’s income and assets are treated differently across programs, ensuring they have sufficient resources to avoid impoverishment. The Community Spouse Resource Allowance (CSRA) and the Monthly Maintenance Needs Allowance (CSMIA) are key elements in this process.
The Look-Back Rule
This rule applies to nursing home Medicaid, scrutinizing asset transfers made within 60 months prior to application. Violations may lead to a penalty period of Medicaid ineligibility.
An important change is coming
A new Look-Back Period will be implemented for Home and Community Based Long-Term Care Services. This is formally called Community Medicaid in NY and includes home health care, adult day care, personal care assistance, and assisted living services. Previously, there was no such period for Community Medicaid. The new “look back” will be 30 months (2.5 years) instead of 60 months as it is for Institutional Medicaid. The earliest the state plans to implement this change is sometime in 2025.
Medical and Functional Need Requirements for New York Medicaid
For eligibility in New York's long-term care Medicaid programs, applicants must demonstrate a functional need. Specifically, Nursing Home Medicaid and Home and Community Based Services (HCBS) Medicaid Waivers require a Nursing Facility Level of Care (NFLOC), determined through an assessment of the individual's needs. Additionally, some program benefits, like cost coverage for home modifications under a Medicaid Waiver, may require proof that the applicant cannot safely and independently live at home without these modifications. For community medicaid, the applicant must demonstrate an inability to meet certain minimum activities of daily living on their own. On the other hand, for services provided through the Regular Medicaid program, while a functional need related to daily activities is necessary, a full NFLOC may not be. This structure ensures that the level and type of care provided aligns closely with the specific needs of each applicant.
Ways to Qualify for New York Medicaid Beyond Income and Asset Limits
For senior residents in New York who exceed the standard financial thresholds for Medicaid, there are several alternative pathways to gain eligibility. These options are designed to accommodate individuals with financial circumstances that disqualify them from conventional Medicaid but who still require assistance due to significant healthcare needs.
New York's Spenddown Program
The Medically Needy Pathway, also known as the Spenddown Program or Surplus Income Program, caters to those whose incomes surpass Medicaid’s standard limits. In 2024, individuals with monthly incomes up to $1,732 and couples up to $2,351, who have substantial medical expenses, can qualify by using their excess income to cover costs like medical supplies and prescription drugs. Once the spenddown amount is met, eligibility is granted for the remainder of the month.
Pooled Income Trusts
For disabled New Yorkers with income levels above the Medicaid threshold, a Pooled Income Trust offers a viable solution. By depositing excess income into this type of trust, individuals can become income-eligible for Medicaid. The funds in the trust are used for the beneficiary's expenses and do not count towards the Medicaid income limit, effectively bypassing the need for a traditional spenddown.
Asset Spend Down
If an individual's countable assets exceed Medicaid's limits, they may reduce their count by spending on allowable expenses. Eligible expenditures include paying off past-due medical bills, home care services, and accessibility modifications like wheelchair ramps and stairlifts. Prepaying funeral and burial costs, as well as settling mortgages or debts, are also permissible. It's crucial to maintain documentation of these expenses to avoid violations of Medicaid's Look-Back Rule and potential penalties.
Medicaid Planning
For those significantly over the financial criteria, Medicaid planning is essential. Working with a New York Medicaid Planning Attorney can help families develop strategies to meet eligibility requirements and safeguard assets, such as the family home, from Medicaid's Estate Recovery Program.
How to Apply for Medicaid in New York
Applications for Medicaid in New York must be made in person at a Local Department of Social Services (LDSS) office or by phone. Unfortunately, there is no online application option for seniors. Assistance with the application process is available through various agencies, including local Area Agencies on Aging.
Conclusion
Navigating Medicaid’s long-term care options in New York can be challenging due to the complexities of eligibility and application processes. Understanding the different types of programs, income and asset rules, and the application procedures can significantly ease the burden for elderly New Yorkers seeking assistance. Always consider consulting with a New York Medicaid planning attorney to ensure compliance and maximize benefits.
