Overview of New York’s Assisted Living Program
The Assisted Living Program (ALP) provides a supportive living environment for elderly and disabled New York residents who are 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. An adult home 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 it 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, which means meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, the program has a limited number of ALP beds, and when these beds are all full, a waitlist for program participation forms.
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 regular Medicaid program. This program is often referred to as Community Medicaid. Interested persons should consider the Managed Long Term Care Program and the Community First Choice Option.
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
– Personal Care Assistance
– Medical Supplies / Equipment
– Nursing Services
– Personal Emergency Response Services (PERS)
– Therapies (occupational, physical, speech)
Eligibility Requirements for NY’s Assisted Living Program
The ALP is for New York residents who are at risk of nursing home placement, but are not 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
The applicant income limit is higher than it is for other NY Medicaid Programs. The limit is equivalent to 100% of the Federal Benefit Rate (FBR), which increases every January, plus the state supplemental payment amount (SSP). In 2021, a single applicant can have a monthly income up to $1,488 ($794 FBR + $694 SSP = $1,488). For married applicants, there is a couple income limit, which is $2,976 / month ($1,191 FBR + $1,785 SSP = $2,976). 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.
For persons who have income under $1,488 / month, SSI will supplement one’s income to bring it to $1,488 if one has assets under SSI’s $2,000 limit. Then, with the exception of $210 / month, all of the income will go to the “assisted living program” for room and board. Persons who do not receive SSI are also limited to a $210 / month personal needs allowance. Assisted living programs cannot charge more than $1,488 / 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. (More below under “Qualifying When Over the Limits”).
In 2021, the asset limit is $15,900 for a single applicant. For married couples, the asset limit is $21,400. 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 is implementing a 30-month look back rule for applicants of long-term home and community based services. Once implemented, violating this rule will result in a penalty period of Medicaid ineligibility.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. 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 to the home and his / her home equity interest is no greater than $906,000 (in 2021). Home equity interest is the current value of the home minus any outstanding mortgage.
– 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.
To learn more about the potential of Medicaid taking the home, click 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 the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating) 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.
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 the state of 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 is in the process of implementing a 30-month look back period, 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.
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. Contact information can be found here. 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 “assisted living program” 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.
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 even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, 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.