New York Medicaid Definition
Medicaid is a wide-ranging, state and federally funded, health care program for low-income individuals of all ages. While there are several different eligibility groups, including pregnant women, children, and disabled individuals, this page is focused on Medicaid eligibility for New York senior residents (aged 65 and over). Specifically, the focus will be on long-term care, whether that be at home, in a nursing home, or in an assisted living facility.
Make note, Medicaid in New York is sometimes referred to as Medicaid Managed Care. Medicaid for the Disabled, Aged or Blind (DAB) is also known as NON-MAGI.
Income & Asset Limits for Eligibility
There are several different Medicaid long-term care programs for which New York seniors may be eligible. These programs have differing functional and financial eligibility requirements, as well as varying benefits. Eligibility for these programs is complicated by the facts that the criteria vary with marital status and that New York offers multiple pathways towards eligibility.
1) Institutional / Nursing Home Medicaid – is an entitlement (anyone who is eligible will receive assistance) & is provided only in nursing homes.
2) Medicaid Waivers / Home and Community Based Services (HCBS) – is not an entitlement (there are a limited number of participants) & is provided at home, adult day care, or in assisted living.
3) Regular Medicaid / Aged Blind and Disabled – is an entitlement (anyone who is eligible will receive assistance) & is provided at home or adult day care.
The table below provides a quick reference to allow seniors to determine if they might be immediately eligible for long term care from a New York Medicaid program. Alternatively, it may be helpful to take the Medicaid Eligibility Test. IMPORTANT, not meeting all of the requirements below does not mean one is ineligible for Medicaid or cannot become eligible. More.
|2020 New York Medicaid Long Term Care Eligibility for Seniors|
|Type of Medicaid||Single||Married (both spouses applying)||Married (one spouse applying)|
|Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required||Income Limit||Asset Limit||Level of Care Required|
|Institutional / Nursing Home Medicaid||$875 / month||$15,750||Nursing Home||$1,284 / month||$23,100||Nursing Home||$875 / month for applicant||$15,750 for applicant & $128,640 for non-applicant||Nursing Home|
|Medicaid Waivers / Home and Community Based Services||$875 / month||$15,750||Help w/ 2 Activities of Daily Living||$1,284 / month||$23,100||Help w/ 2 Activities of Daily Living||$875 / month for applicant||$15,750 for applicant & $128,640 for non-applicant||Help w/ 2 Activities of Daily Living|
|Regular Medicaid / Aged Blind and Disabled||$875 / month||$15,750||None||$1,284 / month||$23,100||None||$1,284 / month||$23,100||None|
What Defines “Income”
For Medicaid eligibility purposes, all income that one receives from any source is counted towards the income limit. This may include employment wages, alimony payments, pension payments, Social Security Disability Income, Social Security Income, gifts, and payments from annuities and IRAs.
When only one spouse of a married couple is applying for nursing home Medicaid or a Medicaid waiver, the income of the non-applicant spouse is not counted, only the income of the applicant. Put another way, the income of the non-applicant spouse is not factored into the applicant spouse’s eligibility. That being said, for Regular Medicaid, the income of both spouses is counted towards the income limit, regardless if one, or both spouses, are applicants. To learn more about what is counted as income and how Medicaid calculates income, click here.
For married couples with just one spouse applying for nursing home Medicaid or a Medicaid waiver, a portion of the applicant’s income can be transferred to the non-applicant spouse (also referred to as the community spouse, the well spouse, or the healthy spouse). As of 2020, up to $3,216 / month can be transferred to the community spouse. If the healthy spouse has monthly income of his or her own, the applicant spouse can only transfer an amount that brings the community spouse’s monthly income to $3,216. This is called the Monthly Maintenance Needs Allowance (MMNA) and is intended to prevent spousal impoverishment.
What Defines “Assets”
Countable assets (often called resources) include cash, stocks, bonds, investments, vacation homes, and savings and checking accounts. However, for Medicaid eligibility purposes, there are many assets that are considered exempt (non-countable). Exemptions include IRA’s and 401K’s in payout status, personal belongings, household items, a vehicle, burial funds up to $1,500, pre-paid funeral agreements (given they cannot be refunded), and one’s primary home, as long as the Medicaid applicant lives in the home and the equity value is under $893,000. However, there is one exception to the home exemption rule, which is if the applicant’s spouse lives in the home. If this is the case, the house is exempt regardless of the equity value.
In order to protect a non-applicant spouse of a Medicaid nursing home applicant or a Medicaid waiver applicant from having too little resources from which to live, there is a Community Spouse Resource Allowance (CSRA). The CSRA allows the healthy spouse to retain a higher portion of the couples’ assets. As of 2020, the community spouse can retain half of the couple’s joint assets, up to $128,640, as the chart indicates above. However, if the couple has more limited assets, the non-applicant spouse is able to retain 100% of their joint assets, up to $74,820.
It is vital that one does not give away assets or sell them for less than fair market value in an attempt to meet Medicaid’s asset limit. This is because New York has a Medicaid Look-Back Period. At the time of this update, the look back rule only applies to Institutional Medicaid and is a period of 60 months (5 years) that dates back from one’s Medicaid application date. During this time frame, Medicaid checks all past transfers to ensure no assets were gifted or sold for less than they are worth. If one is found to be in violation of the look-back period, one will be penalized with a Medicaid penalty period, meaning one will be ineligible for Medicaid for a period of time. That said, an important change is coming January 1, 2021; the Look-Back Period will be implemented for home and community based long-term care services (formally referred to as Community Medicaid in NY), such as home health care, adult day care, personal care assistance, and assisted living services. While the Look-Back Period for Community Medicaid will ultimately be 30 months (2.5 years) instead of 60 months as it is for Institutional Medicaid, it will be phased in. Starting January of 2021, the Look-Back Period will be 3 months and it will increase by one month each subsequent month until it is 30 months in April of 2023.
Qualifying When Over the Limits
For New York residents, 65 and over who do not meet the eligibility requirements in the table above, there are other ways to qualify for Medicaid.
1) Medically Needy Pathway – In a nutshell, one may still be eligible for Medicaid services even if they are over the income limit if they have high medical bills. Also called the Medicaid Excess Income Program, the way this program works is one’s “excess income,” (their income over the Medicaid eligibility limit), is used to cover medical bills, such as medical supplies, prescription drugs, and doctor visits. Once one has paid down their excess income to the Medicaid eligibility limit, Medicaid will kick in for the month. Other names for the Medicaid Excess Income Program include Spenddown Program and Surplus Income Program. This program, regardless of name, provides a means to “spend down” one’s extra income in order to qualify for Medicaid.
Make note, the Medically Needy Pathway does not assist one in spending down extra assets for Medicaid qualification. Said another way, if one meets the income requirements for Medicaid eligibility, but not the asset requirement, the above program cannot assist one in reducing any extra assets. However, there are ways in which one can “spend down” assets and still meet Medicaid’s asset limit. For instance, one can use their excess resources to pay past due medical bills, dating back as far as six years, pay for in-home care, and make home modifications to improve safety and independence, such as installing wheelchair ramps, stair lifts, and redoing a bathroom to be wheelchair accessible. One can also prepay funeral and burial expenses, as well as pay off their mortgage or credit card debt.
Again, it is very important assets are not gifted or sold cheaply in order to meet Medicaid’s asset limit. Doing so is in violation of Medicaid’s Look-Back Period and can result in a period of Medicaid ineligibility. (More information can be found above under the asset section).
2) Medicaid Planning – the majority of persons considering Medicaid are “over-income” or “over-asset” or both, but they still cannot afford their cost of care. For persons in this situation, Medicaid planning exists. By working with a Medicaid planning professional, families can employ a variety of strategies to help them become Medicaid eligible. Read more or connect with a Medicaid planner.
Specific New York Medicaid Programs
1. New York Managed Long Term Care (MLTC) Program Waiver – MLTC is intended for seniors who require a skilled nursing facility level of care, but who prefer to live at home or in an assisted living facility. Long-term care supports are provided to promote independence, including personal care assistance, adult day care, meal delivery, and home modifications.
2. New York Consumer-Directed Personal Assistance Program (CDPAP) – CDPAP can be thought of more as a program option, rather than a program in and of itself, and is available for seniors who are enrolled in the MLTC program or the Community First Choice Option. Through this option, program participants are able to hire the personal care assistant of their choosing, including select relatives.
3. New York Assisted Living Program (ALP) – ALP pays for services in assisted living for seniors who require a nursing home level of care. These services might include skilled nursing, personal care, personal emergency response systems, and housecleaning.
4. New York Community First Choice Option (CFCO) – This is an option that allows elderly individuals to receive long-term home and community based services under the state Medicaid plan. These benefits might include assistance with daily living activities, home health aides, and durable medical equipment.
How to Apply for New York Medicaid
To apply for Medicaid in New York, seniors can apply in person at their local Department of Social Services office, or alternatively, they can call their local office and apply via phone. Unfortunately, at the time of this writing, there is not an option for New Yorkers 65 years of age and older to apply online. For program questions or for assistance with the application process, persons can call the Medicaid Helpline at 1-800-541-2831. In addition, one’s local Area Agency on Aging office may be able to answer program questions and assist persons with applying for Medicaid.
New York Medicaid applicants should be positive that all eligibility requirements, which are covered in detail above, are met prior to submitting an application for benefits. For those seniors who have income and / or asset(s) greater than the allowable amounts, Medicaid planning can be invaluable. In addition, the application process can be quite complicated and assistance with the process may be welcomed. For general information about the application process for long-term care Medicaid, click here.