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Community (Home-Care) Medicaid in New York

Serving Clients in the Five Boroughs and New Jersey


Living safely and comfortably at home for as long as long as possible is a common desire our clients share. Our firm understands this and works with elders and their families to make they enjoy this comfort we all deserve.

Often, successfully aging at home requires the help of others. When facing frailty of old age, a long-term serious illness or the onset of a form of dementia, the need for care in the home is very real. The current focus of the health care system is to favor home health care and in-home services. When a member of a family becomes seriously debilitated the family frequently marshals their funds and energy to provide the initial levels of care needed. That can be draining to a family over time and the high costs of the long-term care impacts the family savings and curtails the ability to continue to privately provide or pay for care.

Soon, families exhausted by the demands of caring for their elders seek government or social services assistance. Caregivers will discover that the system is not so easy to understand. Home care services that are needed may be covered by a variety of sources, from private medical insurance, Medicare for those who are over 65 or disabled, and by Medicaid for those with lower income, aged, blind or disabled. The rules of these programs are different, confusing and complex. Professional guidance in navigating the home care system soon becomes a necessity. The firm of Grimaldi & Yeung LLP provides this necessary guidance and support to our clients who want to be cared for at home. We can develop a care plan with the appropriate financing options that makes sense for you.

Care At-Home Options

Community and Local Sponsored Options

At the onset of an illness, most individuals either rely on their private health insurance to cover short term rehabilitation and curative care to get them back to health, or they look to local social services agencies for help. They may find an informal network of home health aides or services of licensed home care agencies that will work on a fee-for-service basis. In addition, private insurance coverage may provide a few weeks of interim benefits, but often personal savings are tapped or depleted. At this point many individuals look for a government benefit to fill the need. The following publicly funded home care options are available in most localities:

NYS Expanded In-Home Services for the Elderly Program (“EISEP”)

The EISEP program is designed for low-income seniors who do not qualify for Medicaid.This program provides seniors in-home non-medical care services and case management. The goal is to prevent or delay the placement of the frail elderly into more expensive, Medicaid-funded nursing homes. In providing in-home services to seniors and their caregivers, the state hopes both to contain costs and to provide the aged and disabled with the least restrictive form of care. Under EISEP, in some areas of NY, adult children and other relatives can work as paid caregivers to their elderly parents. These services are billed to the senior in need on a sliding scale and are modestly priced but are not entirely free.

In 2011, changes were made to the program to allow for consumer direction of in-home care services (referred to as CDIS). Consumer direction empowers the care recipient to select, train and manage their own care providers instead of the state doing that on their behalf. Participants are able to hire other family members and pay them (with the state’s money) for their caregiving services, provided they meet the program’s requirements. Consumer direction varies from county to county; one should inquire with their local Area Agency on Aging to see about availability.

EISEP services and other local city and county benefits for the aged are available through the local county Area Agency on Aging. In NYC this agency is the NYC Department for the Aging and they will assess the individual in the home and develop a full plan of care including home maker services, friendly visiting, shopping services and Meals On Wheels. The services are limited to a few hours two-to-three times a week and there is a sliding scale contribution assessed for each service.

In addition, program participants must need require assistance with their daily activities. The participant must be aged 60 or older and live at home. However, their care requirements cannot be so severe that the cost of caring for them exceeds the cost to do so in a nursing home. For example, individuals with early-stage Alzheimer’s would be eligible, but those in the late stages of the disease will probably require too much care to remain at home.

EISEP does not have fixed, published income and assets limits However, the program does have cost-sharing rules which impact those participants whose income is greater than 150% of the federal poverty level. Those whose incomes exceed the poverty limits should still pursue assistance from this program. The cost-sharing co-payment EISEP may require is very reasonable and a fraction of the cost of care on the open market. Therefore the services can be cost effective, but the level and duration of services is limited.

EISEP Benefits and Services

The services provided under EISEP may vary from county to county and with each participating individual. The fees for EISEP services are on a sliding scale determined by the participant’s income level. There can be no charge, or a co-payment may be required. If co-payments are required, they are a fraction of what the services would otherwise cost were a home care worker hired. In addition to case management, services may include:

  • Adult Day Care
  • Assistance with the Activities of Daily Living – bathing, grooming, dressing etc.
  • Chore Services
  • Housekeeping / Homemaker Services
  • Meal preparation
  • Medication reminders
  • Personal Emergency Response Services
  • Respite Care
  • Transportation assistance or escorts

Meals On Wheels (MOW)

For those who do not want in-home assistance may benefit from a home-delivered meal. This simple meal service may be the sole act that makes the difference in keeping an elder independent at home. These Meals On Wheels programs are usually offered by local not-for-profit agencies under the direction of the state and local case management services for the elderly or the local senior nutrition programs. The Meals On Wheels representative is an important community gatekeeper who can make the difference in the ability of the senior to remain at home. The nutritional benefit of a daily meal is coupled with the visit of a trained driver who often can spot an emerging health emergency or the need for an intervention.

Medicare Coverage

Original Medicare: Home Health Care Coverage Overview

Medicare is the primary health insurance of older adults and persons with disabilities. Home care services are provided under both Part A (Hospital coverage) and Part B (Community or Outpatient coverage). In order for Medicare to provide home care the following criteria must be met:

  • A physician must certify the need for skilled care on a part-time or intermittent basis
  • There must be a home health care plan in which the skilled services are arranged.
  • The skilled care can be combined with non skilled personal care, but the home care beneficiary must be considered to be “Homebound” (someone who requires assistance when leaving the home)
  • Medicare-covered home care services must be provided by a Certified Home Health Agency (CHHA)

Medicaid Home Care Services

When an individual’s private insurance or Medicare coverage is fully used, individuals and caregivers can look for other solutions for long-term in home care needs of the disabled.

What is Medicaid and why has it become the financing solution for long-term care?

Medicaid is a joint federal, state and city program which provides medical assistance to persons with low incomes and limited assets. It is available to persons who are eligible for public assistance or SSI (Supplementary Security Income.)

In NY State, Medicaid may also be available for persons with higher incomes through the Medicaid Surplus Income Program.
This program usually available for:

  • persons over sixty five years of age
  • the blind
  • the disabled
  • people whose incomes are too high to qualify for public assistance or SSI

Medicaid recipients can spend their income which is in excess of the Medicaid income level on non-covered medical costs and thereby reduce their income. Thus, an over-incomed individual who applies for Medicaid home care services can agree to pay their excess income to the agency providing their care. This means their income is “spent down” on medical care. Often, the amount of excess income paid for care is well below the market fee for service ordinarily charged for the service.

As an alternative to spending down, New York permits Medicaid recipients living in the community and certain congregate care facilities to protect all their income by placing this excess income into income trusts. These income trusts can be created by Medicaid-approved not-for-profits. If an applicant can meet the income and resource eligibility thresholds, Medicaid covers all types of medical care,including hospital care, doctor bills, nursing home coverage, and most importantly home care, and prescriptions.

Since 2012, NYS Medicaid has moved its home care services into a Managed Care System.

Medicare-Financed Home Care

Medicare services are usually provided by Certified Home Health Care Agencies (CHAAs). These agencies range from large non-profits, such as the Visiting Nurse Service of New York, to smaller more customized services affiliated with hospitals or social service agencies. CHAA services are medically focused, must be ‘ordered” by the treating physician, and are evaluated and supervised by registered nurses. Medicare home care services typically last 4-to-6 weeks and rarely provide more than 20 hours per week. It is intended to be rehabilitative, not long-term care.

Private Insurance, Private Pay and Medicaid-Financed Home Care

The largest segment of in-home care is financed by insurance or by private payment. Instead of being limited to medical needs, these services tend to focus on personal care, companionship and assistance with the activities of daily living. They usually focus on keeping individuals safe and independent at home. Services are typically, but not always, provided by licensed home care agencies. If an individual’s resources or insurance are not sufficient to cover the costs of this type of care, Medicaid may cover these costs; however, Medicaid will pay only for licensed services.

Two specialized home care programs are available under Medicaid:

  • The Lombardi Program (Nursing Home without Walls)
  • Consumer-Directed Home Care
  • Managed Long-Term Care

The Lombardi Program (Nursing Home without Walls/NHWW)

Individuals who need complex home care (that’s equivalent to the care provided in a nursing home) will find it in New York’s unique Nursing Home Without Walls Program, also known as Lombardi Services. The program provides basic home health care for approximately 20 hours per week in addition to ancillary and comprehensive services, such as skilled nursing, physical and rehabilitative therapy, transportation to medical appointments, nutrition counseling, home adaptations and equipment, and other specialized support, activities and options. Certified Home Health Agencies (CHAA’s) manage these Lombardi programs.

Consumer-Directed Medicaid Home Care

People living with disabilities and their families have long advocated for greater autonomy. In response to this, Medicaid permits capable recipients to recruit and hire their own home care workers as part of a program called Consumer Directed Home Care Program (CDP). Under CDP, the hired worker must have the legal right to work in the United States, have the proper training and certifications, be in good health, and accept the pay scale offered by the Medicaid agency. This is a joint effort between the Medicaid agency, which provides funding, and the Medicaid recipient, who provides administration (recruiting, hiring and replacing home care workers, in addition to submitting weekly time sheets). CDP provides both flexibility and autonomy for persons with disabilities and their families and caregivers. More information on CDP can be found here.

Managed Long-Term Home Care

As part of New York State’s Medicaid Redesign program initiated in 2012, Personal Care services at home will no longer be managed by the individual’s local social service district, such as HRA in New York City or county-based Department of Health offices. Beginning in July, 2012, Medicaid recipients of personal care, home care and housekeeping will be asked to enroll in a managed care program administered by a private or nonprofit service contracted by New York State’s Department of Health, called a Managed Long-Term Care Program (MLTCP).

These newly developed agencies will be responsible for delivery of the following range of services:

  • Personal care
  • Adult day care
  • Emergency response systems
  • Certified home health agencies (CHHA)
  • Medical supplies
  • Hearing aids
  • Eyeglasses
  • Dental
  • Home modifications and transportation

Home Care is provided by private Managed Long Term Care agencies (MLTC’s) licensed by NYS Local Social Services Districts (“LSSD”). Over fifteen individually managed care companies determine the care plan for all home care services in NYS. The eligibility process is divided into two separate, independent assessments for financial eligibility and the need for care.

Assessment One: Conducted by a RN under the auspices of NY State to determine if home care is an appropriate service plan.
Assessment Two: Conducted by a Managed Long Term Care agency which determines the hours and type of services needed. Strong advocacy is needed to insure that sufficient care is provided. Criteria for how many hours are needed focuses on issues as the applicant’s ability to safely ambulate, toilet and/or transfer, as well as activities of daily living, such as bathing, dressing, and meal preparation. Therefore evidence on these needs and incapacity should be carefully provided by the treating physician documenting the reason the level of home care is needed.

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