Long-term care in New York, like nursing homes, assisted living facilities, and even home health care, are expensive. The average cost of a nursing home in New York is more than $100,000 per year. Private health insurance policies and Medicare generally do not cover long term care, and very few people purchase private long-term care insurance policies. For New Yorkers needing long-term care, Medicaid is the most common source of funding. In 2011, more than 70% of nursing home residents in New York received Medicaid.
Nursing homes are residential facilities that offer round-the-clock skilled nursing care in addition to other supportive services. People who are sixty-five (65) or older, disabled, or blind, can qualify for Medicaid that will cover a nursing home stay if they meet income and asset limits and if they need skilled nursing care.
If you are disabled, blind, or 65 or older, you can qualify for Medicaid if your monthly income in 2014 is $809 or less for a household of one or $192 for a couple. That is equivalent to 87% of the Federal Poverty Level (FPL).
New York’s Excess Income Program does allow individuals to qualify for Medicaid by spending down their income on qualifying medical expenses until they reach Medicaid income limits. For example, if your income is $100/month, but you spend $300/month on medical expenses, then you qualify for Medicaid because you are spending down $300 to bring you under the $809 income cap.
New York also has a program in which you can pay your extra income to the Department of Social Services in order to maintain Medicaid eligibility. In addition, New York allows individuals of any age to establish pooled income trusts to set aside excess income and still qualify for Medicaid. For more information about pooled income trusts, read Nolo's article on putting income in a pooled trust to qualify for Medicaid or consult an attorney.
If you are considering a nursing home stay, remember that New York Medicaid requires nursing home residents to contribute almost all of their monthly income to the cost of their nursing home care. The state allows Medicaid recipients in nursing homes to keep only $50 per month for themselves.
Note about Obamacare: New York has implemented provisions of the Affordable Care Act (ACA) that affect how the state calculates income eligibility for Medicaid. One of the goals of the ACA is to simplify Medicaid eligibility determinations and make them the same in every state. The new way to calculate Medicaid eligibility involves looking at an applicant’s Median Adjusted Gross Income (MAGI). Disabled adults between 21 and 65 who do not yet receive Medicare are eligible to apply for Medicaid using the MAGI standard, which allows more monthly income (up to $1,273/month) and has no resource test. However, MAGI Medicaid does not cover nursing homes or other long-term care services. If you need those services, you must meet the $809 per month income standard.
To qualify for non-MAGI Medicaid, the kind of Medicaid that will cover long-term care services, you must have few resources. Resources are assets, like money in the bank, retirement accounts, land, and personal property like cars. The resource limit for a single person to qualify for non-MAGI Medicaid is $14,550, and it is $21,450 for a married couple who both want to qualify.
Some property does not count toward the resource limit. For example, you are allowed to have up to $814,000 of equity in your home, and you are also allowed to exempt one vehicle.
Medicaid will pay for a nursing home only when having access to skilled care is medically necessary. In New York, when you are admitted to a nursing home, an evaluator will meet with you to review all of your medical conditions and your ability to do some activities of daily living like eating, moving between a bed and chair or wheelchair, using the bathroom, and getting around. The evaluator will use a form called a Hospital and Community Patient Review Instrument (HC-PRI) to assign a particular score to your need for nursing home care. Medicaid uses that information to decide whether you need a nursing home, what kind of nursing home is appropriate for you, and what services Medicaid will pay in the nursing home. In general, for a nursing home to be considered medically necessary, you must have a medical condition that is so serious that you need the level of nursing care that is only available in an institution.
Managed Long-Term Care (MLTC) is a system that provides long-term care services, including nursing home and home health services, for Medicaid recipients through private companies. The state of New York uses Medicaid funds to hire managed care companies to provide recipients with long-term care services. New York is transitioning more and more Medicaid recipients to managed care programs. In New York City and in many other parts of the state, if you are over 21, have Medicaid and Medicare, and need long-term care services, then you must enroll in a managed long-term care program.
There are two basic types of long-term care plans in New York: MLTC Plans and Program for All-Inclusive Care for the Elderly (PACE) Plans. MLTC Plans cover long-term care services and other health services like prescriptions, medical equipment, and dentistry. Participants choose primary care physicians and use their Medicaid and Medicare benefits for payment. PACE participants receive their services from a team of professionals like physicians, nurses, and social workers, whose role is to coordinate individualized care. PACE participants must be at least 55 years old and receiving Medicaid.
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