When Medicaid in New York Will Pay for Assisted Living or Home Health Care

For those who qualify financially, New York's Medicaid program will pay for long-term care for elderly or disabled individuals who require a certain level of medical care and personal care. (Read the first part of this article on income and asset limits and when a nursing home is medically necessary.) In this part of the article, we'll discuss Medicaid coverage of assisted living facilities and home health care services.

When Medicaid Covers Assisted Living Facilities for New Yorkers

An assisted living facility (ALF) provides room and board, therapy and nursing services, and supervision. ALFs are generally less expensive and less medically intensive than nursing homes. Some ALFs are specially licensed by the state to accept Medicaid residents, and those are known as Assisted Living Programs (ALPs). You can find profiles of New York ALPs and identify one near you on the Department of Health's website.

None of the Medicaid managed long-term care programs in New York will cover assisted living facility fees, though they might pay for some home health services while they're in assisted living.

Although Medicaid won't cover the cost of room and board at ALPs, Supplemental Security Income (SSI) may be available to supplement a resident's income and help cover costs.

So if you're 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's not available to everyone who wants it.

To qualify for ALP, you must need a nursing home level of care. Furthermore, you must show that, if it weren't for the ALP, you would have to be placed in a nursing home because you don't have a home or a suitable home environment. At the same time, you can't need 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 $1,732 in 2024 to qualify for an ALP. If both spouses are applying, their income is limited to $3,464 per month.

Most assisted living facilities aren't 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.

ALPs are regulated by the New York State Department of Health. For more information, contact your Local Department of Social Services (LDSS) or call the Department of Health Medicaid Helpline at 1-800-541-2831.

Home Health Care Programs in New York Paid Through Medicaid

Home health care can include:

• skilled nursing or therapy services
• home health aide services like medication management or bathing assistance, and
• personal care aide services like meal preparation or cleaning.

New York's managed care programs Program for All-Inclusive Care for the Elderly (PACE) and Managed Long-Term Care (MLTC) both offer home health services as part of their benefit package, so if you're a participant in those programs, you can receive assistance from skilled nurses, home health aides, or personal care attendants in your home, as long as your doctor or care coordinator has authorized those services for you according to the requirements in your particular managed care plan.

In addition, New York offers personal care assistance to Medicaid beneficiaries through its Personal Care Services Program (PCSP). PCSP covers assistance with in-home activities like housekeeping, bathing, using the toilet, and preparing meals. Your doctor must send a physician's order to your local social services district, and then a nurse assessor will visit your home and interview you about your activities of daily living and your need for assistance. The assessor will decide what kind and how much assistance you need. Generally, your local social services district selects the agency that will provide services to you.

Another way to get personal care assistance is through New York's Consumer Directed Personal Assistance Program (CDPAP). Like for the PCSP, you need a physician's order and a nurse's evaluation to qualify for help. However, in CDPAP, you get to select, train, supervise, and fire (if necessary) your own service providers. That means CDPAP recipients have flexibility and control over their choice and management of caregivers. In addition, CDPAP will cover skilled nursing services in your home, not just personal care services.

Finally, New York has the Long-Term Home Health Care Program (LTHHCP). LTHHCP provides a wide range of services, coordinated by registered nurses, with the goal of allowing individuals who would otherwise be institutionalized to stay in their homes. To qualify for LTHHCP, you must be a Medicaid beneficiary, and you must meet the nursing home level of care. You can get medical and therapy services, home-delivered meals, modifications to your home or assistance moving to a more suitable home, plus social services.

To apply for Medicaid or any of these programs, contact your New York State LDSS.

_{Updated March 22, 2024}