Medicaid Financial Eligibility Rules For Nursing Home Care In New York State Books Pdf File

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Matthew Pendergrass

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Jul 17, 2024, 5:46:37 PM7/17/24

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Thomas J Catalano is a CFP and Registered Investment Adviser with the state of South Carolina, where he launched his own financial advisory firm in 2018. Thomas' experience gives him expertise in a variety of areas including investments, retirement, insurance, and financial planning.

Because these rules vary by state, it may be best to speak directly to a regional office to obtain the correct set of guidelines for your home state. You can find a link to connect you via the Medicaid website.

Medicaid Financial Eligibility Rules for Nursing Home Care in New York State books pdf file

DOWNLOAD https://urlcod.com/2yK1NE

Medicaid is a federal program administered at the state level that's designed to provide medical care assistance for low-income individuals and families and people with disabilities. Medicaid is separate from Medicare, which is a federal program that pays certain health care expenses for individuals ages 65 and older.

Medicaid can help to pay the costs of long-term care in a nursing care facility. To qualify for assistance, you must meet the Medicaid eligibility guidelines established by your state. It's important to note that Medicare does not help with long-term care costs.

The Medicaid lookback period is a period of time (typically five years) in which any transfers of assets to family members may be subject to scrutiny for Medicaid eligibility. If it's determined that you specifically transferred assets during the lookback period in order to qualify for Medicaid, this can affect the benefits for which you're eligible.

To be eligible for Medicaid, you must meet certain guidelines for income and financial assets. If your assets are above the threshold allowed in your state, you may have to spend some of those assets down in order to qualify for Medicaid for long-term care.

Throughout the following section, links to various web pages are provided for reference. Please note that web page addresses change frequently and while the addresses provided were accurate as of the issuance of this Toolkit, if you are unable to access any of the web pages through the links, please refer to the main NYS Department of Health website at _care/medicaid/ and navigate to the information you are seeking.

Medicaid is a health insurance program administered by the New York State Department of Health (DOH) through the Local Departments of Social Services (LDSS) ( _care/medicaid/ldss.htm). Medicaid provides healthcare coverage for people with low incomes, children, people who are aged (65 or older), blind, and/or disabled, and other New York residents who are eligible. Medicaid pays for OPWDD services for New Yorkers with developmental disabilities.

Medicaid eligibility is based on both financial and non-financial factors. Because Medicaid is a needs-based program, applicants must meet certain income and resource requirements to qualify. The primary categories used for people served by OPWDD and its provider agencies are:

All these programs are discussed further below. There are standard requirements for Medicaid eligibility; however, programs exist for people whose income or resources exceed the standard levels. It is expected that people will apply for Medicaid even if they do not appear to qualify based on their income or resources.

While Medicaid eligibility is automatic for SSI recipients, people applying for SSI should also apply separately for Medicaid because SSI applications can take up to 6 months to be processed. SSI payments are not retroactive. SSI payments do not begin until the month after the application is approved. Medicaid, on the other hand, can be retroactive for 3 months. This means that Medicaid can usually be opened prior to an SSI application being approved if they are applied for at the same time. There is also the possibility that a person may be determined ineligible for SSI yet be eligible for Medicaid; therefore, waiting for the SSI decision only prolongs the period for which a person does not have Medicaid coverage.

In New York State, Medicaid is available to United States citizens, qualified non-citizens and undocumented immigrants over the age of 65. Emergency coverage is also available for undocumented immigrants under the age of 65. The following resources are available to help determine whether a person is eligible:

While each county in New York State has a Medicaid office (LDSS) that is generally responsible for handling Medicaid for people living in their counties, NYS also has an online marketplace called the New York State of Health (NYSoH). OPWDD operates a statewide Medicaid district (District 98), which handles Medicaid coverage for most people who live in state-operated residential programs and certain people in some nonprofit agency living arrangements, regardless of the county where they live. Where a person should apply depends on different criteria. See the sections below for more information.

People who do not need OPWDD residential services can apply for health insurance coverage, including Medicaid, online through NYSoH at: Assistance is available by calling 1-855-355-5777, or by contacting an In-Person Assistor (IPA), Certified Application Counselor (CAC) or Navigator. IPAs, CACs and Navigators are trained and certified to assist people and small businesses with the online application process. IPAs and Navigators are available in convenient community-based locations in every county, while CACs may work for entities such as hospitals, clinics, providers or health plans.

For people with developmental disabilities, the chart below shows when Medicaid is the responsibility of OPWDD District 98 and when it is the responsibility of the LDSS. This is based on living arrangement and Chapter 621 status.

People who are Chapter 621-eligible have at least five years of continuous inpatient status in a state facility (i.e., developmental center or psychiatric center) since June 29, 1969. Inpatient status is defined as residential status without discharge or release from the facility/facilities for any period of 90 days or longer.

*Please note that there are times when people who resided in converted residences at the time that they converted, though not Chapter 621-eligible, are the responsibility of District 98 until they move to another residence. This is a limited number of people and any questions about Chapter 621 status should be directed to the local Financial Benefits & Entitlements Assistance & Management (FBEAM).

All Medicaid applicants applying through the local district or through OPWDD District 98 must use the Access NY Health Care application (DOH-4220) . In addition, people requesting HCBS Waiver services and people requiring care in an Intermediate Care Facility (ICF) or Developmental Center (DC) must also file the Access NY Health Care Supplement A (DOH-5178A).

People seeking HCBS Waiver services must provide documentation of their current resources. For ICF/DC care, people must provide documentation of their resources for 60 months prior to the date of application.

Full coverage (Medicaid Coverage Code 01) is necessary for people receiving OPWDD services in institutional settings and requires documentation of resources for the past 60 months. Institutional settings include Intermediate Care Facilities for people with Intellectual Disabilities (ICF/IID), Nursing Facilities (NF), Developmental Centers (DC), and Small Residential Units (SRU). Full coverage pays for all Medicaid covered services and supplies.

People residing in the community should apply for Community Coverage with Community-Based Long-Term Care (Medicaid Coverage Code 19 or 21). This type of coverage pays for all Medicaid covered care and services, including adult day health care, Personal Care, private duty nursing, the assisted living program, OPWDD HCBS Waiver services and Care Management. For this type of coverage, people must document the value of their current resources at initial application. This coverage type does not cover long-term care services in nursing facilities and equivalents, or services provided in an ICF/IID. People with excess countable income will have a spenddown and the Medicaid coverage code will be 21.

Note: Community Coverage without Long-Term Care (Medicaid Coverage Code 20 or 22) does not cover services provided in an ICF/IID or OPWDD HCBS Waiver services and is therefore not appropriate for people applying for OPWDD services. Medicaid coverage code 22 indicates the person has a spenddown.

If the Medicaid district gives an OPWDD HCBS Waiver enrolled individual Community Coverage without Long-Term Care (Medicaid Coverage Code 20 or 22), the person or their representative must request that the coverage type be changed to Community Coverage with Community-Based Long-Term Care (Medicaid Coverage Code 19 or 21).

When a Medicaid applicant makes a prohibited transfer but is otherwise eligible for Medicaid, a penalty period is imposed. During this penalty period, the applicant is not eligible for the following care and services:

The penalty period starts on the first of the month following the month in which the assets were transferred or the date the person is receiving nursing facility services, whichever is later. The length of the penalty period is calculated by dividing the total uncompensated value of the transferred assets by the average regional rate for the nursing facility services in the region. If the uncompensated value of the transferred assets is less than the regional rate or if the penalty period results in a partial month penalty, that amount will be due to the provider of services.

After an application is submitted, the Medicaid district will determine whether the person is eligible and will send a letter notifying the person of acceptance or denial within 45 days of the date of the application. If a disability determination is required, it may take up to 90 days to determine eligibility.