Overview of New York Medicaid’s Managed Long Term Care
New York’s Medicaid Managed Long Term Care (MLTC) Program provides long-term services and supports for chronically ill and disabled residents who are at risk of nursing home placement. While short term nursing home care is available via this program, the program’s main goal is to prevent and delay nursing home admissions by providing home and community based services (HCBS). Program benefits include assistance with activities of daily living (i.e., bathing, dressing, eating, mobility), adult day care, home health care, personal emergency response systems, and home modifications, allowing eligible individuals to live at home or the home of a loved one. It is likely that eligible individuals can also reside in an assisted living residence, although they cannot be simultaneously enrolled in NY’s Assisted Living Program and the MLTC Program. MLTC beneficiaries cannot reside in an adult foster care home.
New York Medicaid Managed Long Term Care Program participants receive long-term care benefits via a single Medicaid plan provided by a managed care organization (MCO), essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers.
There are three types of managed long-term care plans within NY’s Medicaid Managed Long Term Care Program. Two of the three plans streamline all Medicaid and Medicare benefits into one plan, allowing program participants to receive both their Medicaid and Medicare benefits. The three plans are as follows:
1) MLTC Medicaid Plan – Provides long-term care Medicaid benefits. Participants who are on Medicare continue to receive their Medicare benefits via Medicare.
2) Medicaid Advantage Plus (MAP) – Provides long-term care Medicaid benefits and Medicare benefits.
3) Program for All-Inclusive Care for the Elderly (PACE) – Provides long-term care Medicaid and Medicare benefits for program participants 55+ years of age. Learn more about PACE.
There is some flexibility of providers for persons receiving home and community based services via MLTC, as select care services may be consumer directed. This means that rather than receive services by the MCO’s network of licensed care providers, a program participant can hire their own caregiver. This option is called the Consumer Directed Personal Assistance Program (CDPAP). Spouses cannot be hired, but other family members, such as one’s adult child or grandchild, can be hired. A financial management service agency handles the financial aspects of employment responsibilities such as tax withholding and caregiver payments.
Long-term care services via MLTC are an entitlement, which means meeting eligibility requirements equates to immediate receipt of program benefits. Stated differently, there is no waitlist for program participation.
The Medicaid Managed Long Term Care Program operates through a 1115 Demonstration Waiver called the Medicaid Redesign Team (MRT) Waiver. Previously it was called the Partnership Plan.
Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For-Service” or “Managed Care”. Under Fee-For-Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.
Benefits of Managed Long Term Care
Program participants receive long-term care services and supports, as well as additional limited benefits. As mentioned above, Medicare benefits are also provided via some MLTC plans. Follows is a list of potential Medicaid benefits. An individualized plan of care will determine which benefits a program participant will receive. This means meeting waiver requirements does not guarantee receipt of all benefits.
– Adult Day Health Care – provides daytime supervision and personal care assistance in a facility group setting
– Audiology Services – includes hearing aids and batteries
– Care Management
– Consumer Directed Personal Assistance Services – provides the option to hire one’s caregiver via CDPAP
– Dental Services
– Durable Medical Equipment – wheelchairs, etc.
– Home Delivered Meals / Congregate Meals
– Home Health Aides
– Home Modifications
– Medical Supplies – incontinent pads, compression stockings, etc.
– Nursing Home Care – limited to 3 months
– Optometry Services – includes eyeglasses
– Personal Care Assistance
– Personal Emergency Response System (PERS)
– Private Duty Nursing
– Therapies (occupational, physical, and speech)
While likely that MLTC services and supports can be provided in assisted living residences, the cost of room and board in assisted living is not covered. Long-term nursing home care used to be provided via the MLTC Program. However, in 2020, the state began disenrolling nursing home residents of 3+ months from MLTC and began enrolling them in institutional (nursing home) Medicaid.
Eligibility Requirements for NY Medicaid Managed Long Term Care
The Managed Long Term Care Program is for New York residents who are 18+ years of age and chronically ill or disabled who are at risk of nursing home placement. It is a mandatory program for New Yorkers who are 21+ years old, “dually eligible” (eligible for both Medicaid are Medicaid), and assessed as needing long term care for more than 120 days.
Financial Criteria: Income, Assets & Home Ownership
In 2021, the individual income limit is $884 / month, and the couple income limit, with both spouses as applicants, is $1,300 / month. When only one spouse is an applicant, the individual income limit of $884 / month is used. Stated differently, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. In New York, this is called a community spouse monthly income allowance (CSMIA) and allows an applicant spouse to bring his / her non-applicant spouse’s monthly income up to $3,259.50. The maximum amount that can be transferred is $3,259.50 / month and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own monthly income equal to or greater than $3,259.50 are not entitled to a spousal income allowance. Furthermore, it is requested that non-applicant spouses with monthly income greater than $3,259.50 contribute 25% of their “excess” income towards the applicant spouse’s care costs.
In 2021, the asset limit is $15,900 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $21,400. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $15,900 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.
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 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, New York Medicaid 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) to be eligible for the MLTC Program. Furthermore, an applicant must require long-term care for more than 120 days. The Uniform Assessment System (UAS-NY) eligibility assessment tool is used to make this determination and is completed by a registered nurse from the NY Medicaid Choice’s Conflict-Free Eligibility & Enrollment Center (CFEEC). To meet the 120 day minimum requirement, hands on assistance with three activities of daily living (i.e., bathing, dressing, mobility, etc.) is required. An exception exists for persons with Alzheimer’s Disease or a related dementia; physical assistance is not required. Instead they must require supervision of two activities of daily living.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for New York Medicaid. There are a variety of planning strategies that can be used to help persons 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, the MLTC Program will pay for services and supports.
When persons have assets over the limits, one option is to “spend down” 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. 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 Medicaid Managed Long Term Care
Before You Apply
Prior to applying for the MLTC Program, applicants need to ensure they meet the 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. Take a 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, 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.
To apply for the MLTC Program, applicants must be eligible for New York Medicaid. State residents can apply via their local Department of Social Services (DSS) office. Applicants must also call NY Medicaid Choice’s Conflict-Free Evaluation & Enrollment Center (CFEEC) at 1-855-222-8350 to request a “conflict-free eligibility determination”, or in other words, a functional needs assessment. Once an applicant is determined eligible for the MLTC Program, a MLTC plan is chosen, and a second assessment will be completed and an individualized care plan created. Persons can contact New York Medicaid Choice at 1-888-401-6582 with questions about managed care enrollment, assistance with choosing a plan, and to enroll in a plan. Plans are assigned to eligible persons who do not select one. For additional information about the MLTC Program, click here.
The New York State Department of Health (DOH) administers the Medicaid Managed Long Term Care Program and the Department of Social Services (DSS) office determines 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.