How do I apply for home care services through Medicaid?

Most New Yorkers obtain home care services through the State’s Medicaid program because they need help with everyday tasks and want to remain at home. Below is an overview on how to apply for home care services when you already have Medicaid health insurance.

What are long-term care services?

• Long-term care services include: private duty nursing services, home care (personal care), adult day care, and Consumer directed personal assistance services (CDPAS).
• Medicaid beneficiaries must apply for long term care services before they start receiving them. This means that long term care services require prior authorization and approval.

What are activities of daily living (ADLs)?

• In order to qualify for Medicaid home care, you must show you need help with activities of daily living (ADLs). ADLs refers to the fundamental tasks and skills that are required for one to live an independent life.
• Level I ADL tasks include: telephone use, preparing meals, ordinary housework, managing finances, and shopping.
• Level II ADL tasks include assistance with: medication management, bathing, personal hygiene/grooming, dressing upper & lower body, eating, ambulating/walking, transferring, toileting, incontinence care, and bed mobility.
• Currently, Medicaid recipients need to show that they are medically stable, can direct their own care or have someone that can direct care on their behalf, and need assistance with at least one Level II ADL task in order to qualify for Medicaid home care services.
  

New York Independent Assessor (NYIA)—Scheduling your home care assessment

• Before you can get Medicaid home care, you have to be assessed by the New York Independent Assessor (NYIA), a NYS Department of Health program whose primary purpose is to determine eligibility for Medicaid home care.
• NYIA is responsible for scheduling and completing initial assessments for most Medicaid beneficiaries who are adults (18 and over) who are seeking personal care or consumer directed services for the first time.
• The NYIA process also applies to Medicaid recipients seeking enrollment into a Medicaid managed long-term care plan or Medicaid Advantage Plus Plan.
• To make a NYIA appointment, call 855-222-8350. For general information about NYIA, visit https://nyia.com/en.

What should I expect when I call NYIA?

• NYIA will schedule 2 appointments with you. The first appointment is for an initial Community Health Assessment (CHA). The second appointment is a clinical appointment. The two appointments must be scheduled and completed within 14 days of you calling them. They can be conducted in-person or via telehealth.
• NYIA will only conduct the initial assessment process for individuals with Medicaid (the only exception is for Immediate Need requests). They will not schedule an assessment if your Medicaid application is still pending.
• The CHA is used to determine eligibility for home care services, enrollment into MLTC plans and voluntary transfers from a Medicaid mainstream plan to a MLTC plan. The CHA is completed before the clinical appointment. If the CHA doesn’t happen on the scheduled date, the clinical appointment will also be rescheduled.
• The clinical appointment is when you meet a clinician who will review the CHA, examine you, determine whether you meet the requirements for Medicaid home care, including whether you can enroll in an MLTC or MAP plan. From these assessments, the clinician will complete a Practitioner’s Order.
• The NYIA assessments and Practitioner’s Order are valid for 12 months for both home care service authorizations and MLTC eligibility purposes.
• Once the two appointments are completed, NYIA will mail you a letter with a determination on whether you are eligible for home care services.

What documents should I provide NYIA?

• If you want someone to act on your behalf, you should complete an authorized representative form and fax it to NYIA at 917-228-8601. The form can be found here: https://nyia.com/content/dam/digital/united-states/newyork/nymc-ia/language-masters/en/pdf/MM-CF-0822.pdf.
• If you want to give your medical providers permission to share your health information with NYIA, you need to fill out a consent form that is found here: https://nyia.com/en/consent.
  
• Have a doctor’s letter and other medical documents available and try to provide them to the assessor during the CHA or clinical appointment and keep copies of documents provided.
  

After NYIA completes their assessments, how are home care services accessed?

• If NYIA finds you eligible for Medicaid home care, how you access home care services depends on the type of Medicaid health insurance you have, whether you are already in a Medicaid managed care plan, or if you need to enroll in a Managed Long Term Care plan to begin receiving services.
• If you have Fee-for-Service Medicaid, you must provide a copy of the NYIA approval letter to your district of social services or HRA in NYC. If you are enrolled in a Medicaid managed care plan, you provide the NYIA approval to your plan. Once LDSS/HRA and the MMC plan have the approval letter, they will develop a plan of care and authorize services.
• If you have Medicaid and are required to enroll in a Managed Long-Term Care (MLTC) plan to get home care services, once you receive your NYIA approval letter, you can call NYIA again or New York Medicaid Choice to discuss your MLTC plan options. https://www.nymedicaidchoice.com/en/find-long-term-care-plan.

Types of Medicaid programs and plans in New York State

• Medicaid Fee-For-Service: Most Medicaid recipients do not have Medicaid fee-for-service. Someone may have Medicaid fee-for-service if they have third party health insurance through Medicare, an employer, a spouse, or a parent; they are enrolled in a Medicaid waiver program like OPWDD, NHTD, some children’s waiver programs; are enrolled in a home hospice program; or require housekeeping only.
• Medicaid Managed Care plan or mainstream Medicaid plan: Most Medicaid beneficiaries in New York State are enrolled in a Medicaid managed care plan. These plans are designed for people with no other health insurance. If you have other health insurance through work or Medicare, you cannot be in a Medicaid managed care plan.
• Managed Long Term Care plan: For Medicaid beneficiaries who have Medicare and Medicaid, known as “dual eligibles,” they are prohibited from enrolling or staying enrolled in Medicaid managed care plans (MMC). They can only enroll in plans especially designed for people with Medicare and Medicaid called Managed Long-Term Care (MLTC) plans:
  • Medicaid Advantage (no home care services in its benefits package)
  • Managed Long Term Care (MLTC)
  • Medicaid Advantage Plus (MAP)
  • Program for All-Inclusive Care for the Elderly (PACE)
  • Fully Integrated Dual Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD)

What if I get denied home care services or my plan approves very few home care hours?

• Medicaid beneficiaries are entitled to written notice from NYIA and the Medicaid program.
• If NYIA determines you do not qualify for Medicaid home care and/or that you do not qualify to enroll in a Managed Long Term Care (MLTC) plan, NYIA must provide you with a written notice that you can appeal.
• If you receive a denial letter from NYIA, you can appeal a denial within 60 days from the date of the notice by requesting a fair hearing through the Office of Temporary & Disability Assistance (OTDA), https://otda.ny.gov/hearings/request/.
• If you receive a denial letter from a Medicaid managed care plan or MLTC plan, you need to first submit an “internal appeal” within 60 days from the date of the notice and wait for a decision. If you are denied again by the plan, then you can request a fair hearing or external appeal.
• If you were denied by NYIA, were approved for too few home care hours, or you requested additional home care hours and the request was denied, you should call Legal Services NYC’s helpline at 917-661-4500 to request legal help.

For free legal help, call Legal Services NYC at 917-661-4500 Monday through Friday from 9:30 a.m. to 4 p.m. Learn more about our intake process here.

* The information does not constitute legal advice. You should always consult an attorney regarding your matter. Legal help subject to capacity and location.