When people apply for Medicaid to receive long-term care at home, they often assume the hardest part is the Medicaid application itself and once they are approved, they have nothing left to do. While establishing eligibility and securing approval is certainly challenging and requires proper guidance, there’s an entirely separate process for applying and receiving actual home care services.

Once you receive Medicaid approval, you must begin the home care evaluation process. Under New York State Medicaid, this involves three distinct parts.

The Home Care Evaluation Process

• Parts 1 and 2: The New York Independent Assessor (NYIA)

The first two parts are conducted by the New York Independent Assessor’s office (NYIA), an entity tasked by New York State Medicaid to screen all potential applicants to determine whether or not they meet state criteria for home care services.

What are the eligibility criteria?

To qualify, you must demonstrate the need for physical assistance with at least three activities of daily living (ADLs). These activities include:

• Dressing
• Bathing
• Toileting
• Walking
• Transferring (going from standing to seated and vice versa)
• Grooming
• Eating

It’s important to note that laundry, housekeeping, medication management, supervision, and safety issues are not considered activities of daily living under NYIA.  These factors will not count toward your assessment for services if you do not meet the ADL criteria.

Beyond meeting the three ADL requirements, you must also prove that you need this assistance daily. Specifically, you need to show that you’ve required help for at least the past three days and will continue to need it for at least the next four months.

The state conducts their assessments in two parts:

1. Nursing Assessment: Conducted by a nurse, this focuses on calculating ADL needs, level of help and frequency of need.  This comprehensive evaluation lasts about 2.5 hours
2. Clinical Assessment: Conducted by a nurse practitioner or doctor, this piece focuses on ensuring the applicant’s care needs can be met in the community. This assessment takes approximately 15 to 20 minutes

• Part 3: Managed Long-Term Care (MLTC) Program Evaluation

If you meet both NYIA assessment criteria, you proceed to the third part: evaluation by a Managed Long-Term Care (MLTC) program. These programs are insurance plans contracted by New York State to manage Medicaid home care services.

Understanding the MLTC System

MLTC programs receive a fixed monthly premium for each member they enroll, regardless of the level of care provided. Whether they approve five hours per week or forty, they receive the same payment. This creates a financial incentive for these programs to authorize the minimum number of hours they can justify, thereby maximizing their profit margin.

What You Need to Know Going Forward

Given the complexities of this system, it’s crucial to understand your (or your loved one’s) needs clearly and be able to express them in a way that will generate an approval for appropriate care. However, you should also be prepared for the possibility that the approved level of care may fall short of what you believe is required.

If Approved Hours Are Insufficient

When the hours approved by Medicaid don’t meet your needs, you have several options to consider:

• Supplement With Private Funds: If you are able, you can pay out-of-pocket for additional home care hours beyond what Medicaid will cover.
• Medicaid-Assisted Living Facility: Consider transitioning to a facility-based setting for care if you (your loved one) can’t get what they need at home.
• Nursing Home Care: In some cases, a nursing home may be the only viable alternative for proper care.

Unfortunately, you must be prepared for the reality that your offer of home care may prove to be inadequate and Medicaid home care ceases to be a viable option if you cannot supplement any approved hours with private funds or other family support. 

The Importance of Professional Guidance

The current criteria for Medicaid home care services are extremely stringent, making professional support essential throughout this process. Just as guidance is critical for obtaining Medicaid approval, expert assistance with applying for home care services is equally important. Navigating the evaluation process, understanding how to present your needs effectively, and knowing your options when approvals fall short can make the difference between receiving adequate care and facing difficult alternatives. We strongly recommend seeking professional support to help you through every stage of this complex journey.