For those who qualify financially, New York's Medicaid program will pay for long-term care for elderly or disabled folks 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.
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 a nursing home. Some ALFs are specially licensed by the state to accept Medicaid residents, and those are known as Assisted Living Programs (ALPs). You can find an ALP near you here.
None of the managed long-term care programs in New York will cover assisted living facility fees.
If you are 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 is not available to everyone who wants it.
To qualify for ALP, you must need the nursing home level of care. Furthermore, you must show that, but for the ALP, you would have to be placed in a nursing home because you do not have a home or a suitable home environment. At the same time, you cannot require 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 $1,608 in 2023 to qualify for an Assisted Living Program. If both spouses are applying, their income is limited to $3,216.
Most assisted living facilities are not 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.
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 Yorks' 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 are 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 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 provider(s). 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 a 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, and social services.
To apply for Medicaid or any of these programs, contact your local department of social services in New York.
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