Applying for New York State Medicaid for long-term care can be a complex and challenging process. But the challenges don’t end there. Accessing home care services once Medicaid approval is granted brings its own complications.
Step 1: The NYIA Assessment
After receiving your Medicaid number, the next step is to undergo an assessment by the New York Independent Assessor’s Office (NYIA). This evaluation consists of two parts: (1) a nursing assessment and (2) a clinical assessment.
These assessments determine whether you meet the state’s requirements for Medicaid home care services and assess how much care you may qualify for.
Step 2: Choosing a Managed Long-Term Care Plan (MLTC)
Once approved by NYIA, you will move on to selecting a Managed Long-Term Care (MLTC) plan. MLTC plans are private insurance companies contracted by Medicaid to manage your home care services. They receive a fixed monthly payment per enrollee, regardless of the level of care needed. This payment covers:
• Home care services. This provides assistance from a home care aide. You can choose a licensed agency aide or opt for the Consumer Directed Personal Assistance Program (CDPAP), which allows you to select your own caregiver—even a family member.
• Adult day care: These programs offer daytime care, including transportation, supervision, and socialization.
• Incontinence supplies and durable medical supplies: These are provided if not already covered by Medicare.
• Case management: This component covers monthly calls from your plan’s case manager.
MLTC plans assess task-based needs, such as activities that a person cannot perform independently without significant assistance. However, MLTC plans do not cover supervision or safety-related care. For example, if you are at high risk for falls or have dementia and cannot be left alone, you will not receive home care hours for safety or supervision needs. This limitation can make it difficult to obtain the necessary care for individuals with such needs.
Additionally, because MLTC plans receive fixed reimbursement rates, they may attempt to limit the plan of care to stay within their budget, even if significant care is needed. This can create barriers to securing the level of care required.
Step 3: Preparing for Your Evaluations
The New York State assessment generates a score based on your responses during the interview. Understanding how to score high enough to receive the necessary home care hours is crucial for your well-being. The following examples illustrate how a score can be influenced:
• Medications supporting your diagnosis can influence your score. If you have a heart disease diagnosis but are not taking related medication, it will carry less weight.
• Claims that a loved one is at high risk for falls or cannot be left alone due to dementia will not necessarily increase your approved hours.
• If family members are available to assist with activities such as shopping, meal preparation, and laundry, it may reduce the number of care hours offered.
Being educated and prepared for your assessments are key to securing the best possible care. Working with and having an advocate present during the nursing portion of the NYIA evaluation will likely achieve a much better outcome, such as a higher offer of home care hours.
There are alternatives to MLTC plans, such as PACE (Programs of All-Inclusive Care for the Elderly), which offers some benefits but also has limitations in terms of hours. This program works better than MLTC plans for some families.
If a MLTC or PACE plan does not provide sufficient care despite every effort, you may need to consider the Nursing Home Transition and Diversion (NHTD) program. This home care program works well for individuals requiring high levels of care and can provide additional support when properly navigated.
Navigating your options and maximizing your benefits can be overwhelming. Expert professionals can guide you through the process, help you prepare for assessments, and advocate for the best possible care and program.
Colin Sandler, LCSW, CCM, is owner of Medicaid Solutions, 2127 Crompond Road, Cortlandt Manor, NY. She has been providing advice on aging to seniors and their families for over 20 years. Email her at Colin@Medicaidsolutions.com or call 914-924-2566
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22 Feb 2025
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Applying for New York State Medicaid for long-term care can be a complex and challenging process. But the challenges don’t end there. Accessing home care services once Medicaid approval is granted brings its own complications.
Step 1: The NYIA Assessment
After receiving your Medicaid number, the next step is to undergo an assessment by the New York Independent Assessor’s Office (NYIA). This evaluation consists of two parts: (1) a nursing assessment and (2) a clinical assessment.
These assessments determine whether you meet the state’s requirements for Medicaid home care services and assess how much care you may qualify for.
Step 2: Choosing a Managed Long-Term Care Plan (MLTC)
Once approved by NYIA, you will move on to selecting a Managed Long-Term Care (MLTC) plan. MLTC plans are private insurance companies contracted by Medicaid to manage your home care services. They receive a fixed monthly payment per enrollee, regardless of the level of care needed. This payment covers:
• Home care services. This provides assistance from a home care aide. You can choose a licensed agency aide or opt for the Consumer Directed Personal Assistance Program (CDPAP), which allows you to select your own caregiver—even a family member.
• Adult day care: These programs offer daytime care, including transportation, supervision, and socialization.
• Incontinence supplies and durable medical supplies: These are provided if not already covered by Medicare.
• Case management: This component covers monthly calls from your plan’s case manager.
MLTC plans assess task-based needs, such as activities that a person cannot perform independently without significant assistance. However, MLTC plans do not cover supervision or safety-related care. For example, if you are at high risk for falls or have dementia and cannot be left alone, you will not receive home care hours for safety or supervision needs. This limitation can make it difficult to obtain the necessary care for individuals with such needs.
Additionally, because MLTC plans receive fixed reimbursement rates, they may attempt to limit the plan of care to stay within their budget, even if significant care is needed. This can create barriers to securing the level of care required.
Step 3: Preparing for Your Evaluations
The New York State assessment generates a score based on your responses during the interview. Understanding how to score high enough to receive the necessary home care hours is crucial for your well-being. The following examples illustrate how a score can be influenced:
• Medications supporting your diagnosis can influence your score. If you have a heart disease diagnosis but are not taking related medication, it will carry less weight.
• Claims that a loved one is at high risk for falls or cannot be left alone due to dementia will not necessarily increase your approved hours.
• If family members are available to assist with activities such as shopping, meal preparation, and laundry, it may reduce the number of care hours offered.
Being educated and prepared for your assessments are key to securing the best possible care. Working with and having an advocate present during the nursing portion of the NYIA evaluation will likely achieve a much better outcome, such as a higher offer of home care hours.
There are alternatives to MLTC plans, such as PACE (Programs of All-Inclusive Care for the Elderly), which offers some benefits but also has limitations in terms of hours. This program works better than MLTC plans for some families.
If a MLTC or PACE plan does not provide sufficient care despite every effort, you may need to consider the Nursing Home Transition and Diversion (NHTD) program. This home care program works well for individuals requiring high levels of care and can provide additional support when properly navigated.
Navigating your options and maximizing your benefits can be overwhelming. Expert professionals can guide you through the process, help you prepare for assessments, and advocate for the best possible care and program.