New York Medicaid Assisted Living Program: Benefits, Eligibility & How to Apply

Last updated: April 26, 2023

 

Overview of New York’s Assisted Living Program

The Assisted Living Program (ALP) provides a supportive living environment for New York residents who are elderly or disabled and at risk of nursing home admission. Intended to prevent and / or delay the need for nursing home care, ALP beneficiaries receive personal care assistance, housekeeping services, home health services, and personal emergency response systems in a long-term adult care facility that is licensed as an “Assisted Living Program”. To be clear, “Assisted Living Programs” are not private assisted living residences. Rather, an “Assisted Living Program” is generally a unit within an adult home, which is a type of adult care facility that provides 24-hour care and supervision for 5 – 200 residents.

Medicaid will pay for the long-term care and supports available via this program, but will not cover the cost of room and board. However, ALP is unique in that SSI will supplement one’s income in order to cover the room and board portion for persons with limited income and assets. Program participants who do not qualify for SSI can pay privately. While the majority of program participants are Medicaid eligible, this program is also open to persons who are not eligible for Medicaid.

While many Medicaid programs allow participants the option to self-direct their personal care services, meaning they can hire the caregiver of their choosing, the Assisted Living Program does not.

ALP is not an entitlement program; meeting eligibility requirements does not equate to immediate receipt of program benefits. The Assisted Living Program has a limited number of available beds for program beneficiaries. When all the beds have been filled, a waitlist forms. However, another option for assisted living services exists. New York residents may be able to reside in private assisted living residences and receive Medicaid-funded personal care assistance via NY’s Medicaid State Plan. This program is often called Community Medicaid. Interested persons should consider the Managed Long Term Care Program and the Community First Choice Option.

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Benefits of the Assisted Living Program

In addition to room and board, follows is a list of the benefits available via New York’s Assisted Living Program. Based on one’s financial means, a ALP beneficiary may be responsible for paying the room and board portion out-of-pocket. However, the monthly fee is well below that of a private assisted living residence.

– Adult Day Health Care
– Case Management
– Home Health Aides
– Housekeeping
– Personal Care Assistance
– Medical Supplies / Equipment
– Nursing Services
– Personal Emergency Response Services (PERS)
– Supervision
– Therapies (occupational, physical, speech)

 

Eligibility Requirements for NY’s Assisted Living Program

 The American Council on Aging now offers a free, quick and easy New York Medicaid Eligibility Test for seniors requiring long-term care. Start here

The ALP is for New York residents who are at risk of nursing home placement. They cannot be bedridden, require around-the-clock nursing services, or present a danger to other residents. Additional eligibility criteria are as follows:

Financial Criteria: Income, Assets & Home Ownership

Income
In 2023, an individual can have monthly income up to $1,677. For married applicants, there is a couple income limit of $3,216 / month. While some long-term care Medicaid programs allow a non-applicant spouse to receive an income allowance from an applicant spouse, called a Monthly Maintenance Needs Allowance, this rule generally does not apply to the ALP.

Program participants are responsible for paying room and board costs. This is usually covered by their own income. For persons who have income under $1,608 / month, which is the SSI maximum benefit for Congregate Level 3 for an individual, SSI may supplement their income to bring it up to $1,608. However, their assets must be under SSI’s $2,000 limit. Then, with the exception of $240 / month as a Personal Needs Allowance (PNA), all of the income will go to the “Assisted Living Program” for room and board. Persons who do not receive SSI are expected to pay $1,677 / month towards room and board, with the exception of a $240 / month PNA. Assisted Living Programs cannot charge more than $1,677 / month for room and board per program participant. Persons who have income in excess of this amount, must “spend down” their extra income to become Medicaid eligible.

Assets
In 2023, the asset limit is $30,182 for a single applicant. For married couples, the asset limit is $40,821. Some NY Medicaid programs allow a non-applicant spouse to be allocated a larger portion of a couple’s assets, called a Community Spouse Resource Allowance. Unfortunately, in most cases, this rule is not relevant for the Assisted Living Program.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value prior to applying for long-term care Medicaid. This is because NY Medicaid will be implementing a 30-month Look-Back Rule no sooner than March 31, 2024 for applicants of long-term home and community based services. Once implemented, violating this rule will result in a Penalty Period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our NY Medicaid Spend Down Calculator

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. Fortunately, for eligibility purposes, Medicaid in New York considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “Intent” to Return, and in 2023, their home equity interest is no greater than $1,033,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– A non-applicant spouse lives in the home.
– The applicant has a disabled child living in the home.
– The applicant has a minor child (under 21 years old) living in the home.

Learn more about the potential of Medicaid taking the home here.

 

Medical Criteria: Functional Need

An applicant must require a Nursing Facility Level of Care (NFLOC). For the Assisted Living Program, the Uniform Assessment System (UAS-NY) eligibility assessment tool is used to make this determination. An applicant’s need for assistance with Activities of Daily Living (i.e., transferring from the bed to a chair, mobility, eating, toileting, bathing) will be considered. A diagnosis of Alzheimer’s disease or a related dementia in and of itself does not mean one will meet the functional need. Furthermore, an applicant must undergo screenings and assessments by the “Assisted Living Program” to determine if the residence can meet one’s needs. This generally includes a physical exam, an interview, a functional needs assessment, and a mental health evaluation.

 Learn more about long-term care Medicaid in New York here

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons in New York who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

When persons have income over the limit, Pooled Income Trusts can help. “Excess” income is deposited into the trust, no longer counting as income. NY also has a Medicaid Spend-Down Program that permits applicants to spend “excess” income on medical bills in order to meet Medicaid’s income limit. The amount that must be paid each month can be thought of as a deductible. Once one’s “deductible” has been met for the month, Medicaid will pay for services and supports.

When persons have assets over Medicaid’s limit, one option is to “spend down” the extra assets. Examples include paying off debt, making home modifications for accessibility and safety purposes, and purchasing pre-paid funeral and burial expense trusts called Irrevocable Funeral Trusts. For married couples, in which only one spouse is an applicant, Spousal Refusal, is an option. Essentially, non-applicant spouses refuse to contribute their share of assets (and income) towards the care costs of their applicant spouse. This strategy not only preserves assets (and income) for non-applicant spouses, but also reduces the amount of countable assets used in calculating the applicant spouse’s Medicaid asset eligibility. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in New York to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. There are also planning strategies that not only help one meet Medicaid’s financial criteria, but also protects assets from Medicaid’s Estate Recovery Program, preserving them for family as inheritance. For example, a Lady Bird Deed allows one’s home to be transferred automatically to a beneficiary upon one’s death, protecting it from estate recovery. Historically, NY has not had a Medicaid Look-Back Period for Medicaid long-term home and community based services. However, the state will be implementing a 30-month Look-Back Period no earlier than March 31, 2024, and certain planning strategies will violate this rule. Therefore, these strategies should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.

 

How to Apply for NY’s Assisted Living Program

Before You Apply

Prior to applying for the Assisted Living Program, applicants need to ensure they meet the program’s eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Although not required for ALP, Medicaid beneficiaries make up the vast majority of ALP participants. Take the Medicaid Eligibility Test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, previous bank statements, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

Since the Assisted Living Program is not an entitlement program, there may be a waitlist for program participation. Via the ALP, there is approximately 10,000 assisted living beds available throughout the state. In the case of a waitlist, an applicant’s access to a participant slot is based on one’s need for care. A person with a greater need for care should be awarded a bed before someone with a lesser need.

 

Application Process

Applicants must be eligible for NY Medicaid in order for Medicaid to pay for care services via the Assisted Living Program. To apply, applicants can contact their local department of Social Services office. Alternatively, persons can call the Medicaid Helpline at 1-800-541-2831. Current Medicaid recipients should contact an “Assisted Living Program” directly and request an initial screening to determine if one’s needs are suitable for the program. Persons can search for Assisted Living Program beds here and contact the facility of their choosing. Make sure to search for “Assisted Living Program” beds rather than Assisted Living Residence beds. Medicaid will need to approve payment of services.

Learn more about the ALP here. Persons can also contact their county DSS office.

The New York State Department of Health administers the Assisted Living Program and the New York State Department of Social Services determines Medicaid eligibility.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. Furthermore, as wait-lists may exist, approved applicants may spend many months waiting to receive benefits.

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