New York Medicaid Nursing Home Eligibility Information & Rules For 2019 Last Updated April 02, 2018

New York Medicaid Eligibility Information 2019
Medicaid Eligibility Requirement Single Married
2019 New York Medicaid Income Limits $Medical Spend Down Allowed $Medical Spend Down Allowed
2019 New York Medicaid Asset Limits $15,150 $22,200
2019 New York Medicaid Home Equity Limit $858,000 $858,000

New York Medicaid

Long-term care in New York, such as assisted living facilities, nursing homes and even home health care, is rather expensive. According to sources, the average annual cost of a nursing home in the state is over $100,000. Long-term care is not covered by Medicare and private health insurance policies, and not many people buy private long-term care insurance policies. For those in New York who need long-term care, the most common funding source is Medicaid.

New York Medicaid Statistics

From the calendar year 2000 through Calendar Year 2013, Department of Health Medicaid enrollment in New York increased by over 2.5 million. Overall spending on the program by the Department of Health increased by 50% over this same period. In the year 2013, services for aged and disabled beneficiaries represented roughly 60% of Department of Health Medicaid expenditures. Reports also suggest that the state spends over $22,000 for each of these elderly or disabled recipients. This was despite the fact that only 1 in 4 beneficiaries were in these categories.

According to expense reports filed by the Department of Health with the federal Centers for Medicare and Medicaid Services, during State Fiscal Year 2013 to 2014, the federal government is said to have paid 51.7% of $55.3 billion in New York’s Medicaid spending. While in recent years, federal aid for the program in the State has increased, the base Medicaid matching rate of 50% in the state is at a statutory minimum. According to reports, the State paid 32.5%, or $18.0 billion, while governments of New York City and the county paid 15.9%, or $8.8 billion.

Eligibility for Medicaid Benefits in New York

In New York, the Medicaid program is called Managed Long-Term Care (MLTC) and is administered by the New York State Department of Health. As the state transforms its system of long-term care to one that ensures care management for all, it may be mandatory or voluntary to enroll in an MLTC plan, depending on individual circumstances.

It is mandatory to enroll in an MLTC plan for those who:

  • Have dual eligibility – meaning that they are eligible for both Medicare and Medicaid – and over the age of 21 and require community-based long-term care services for over 120 days.
  • Are residents of the counties of NYC, Suffolk, Nassau or Westchester.

Voluntary enrollment in an MLTC plan is for those who:

  • Have dual eligibility, are aged 18 to 21 years, and require community-based long-term care services for over 120 days and assessed as eligible for nursing home care.
  • Do not have dual eligibility, over the age of 18 and are assessed as eligible for nursing home care.

There are certain eligibility rules that individuals who want to qualify for Medicaid Benefits in New York are required to meet. These eligibility rules are as follows:

  • They must be aged 65 years or older and need the level of care provided by nursing facilities.
  • They must be a U.S. citizen and a resident of New York.
  • They must meet the monthly income and asset limits for New York.
  • It must be proven to be Medically Necessary for them to be enrolled in a nursing home. In New York, this is done via a Hospital and Community Patient Review Instrument form which a health care professional will provide. This form helps give a better understanding as to what level of care the individual requires, and whether or not a nursing home is necessary and suitable.

When Medicaid is Medically Necessary

Medicaid will pay for a nursing home only when it is medically necessary for an individual to have access to skilled care. When you are admitted to a nursing home in New York, an evaluator will meet with you to conduct a review of all your medical conditions as well as your ability to perform daily activities such as eating, using the bathroom, moving between a bed and a chair or a wheelchair and getting around. As mentioned above, a Hospital and Community Patient Review Instrument form will be used by the evaluator to assess your health and assign a particular score to understand if you require nursing home care.

The information on the Hospital and Community Patient Review Instrument form will be used by Medicaid to decide whether you require a nursing home, the right type of nursing home for your needs, and what nursing home services, it will pay. In general, for it to be considered medically necessary for you to be admitted to a nursing home, you must have a medical condition that is serious enough to require the level of nursing care that only such facilities are able to provide.

Medicaid Program in New York

Unlike in most other states where there are more well-proportioned Medicaid benefits for nursing home care, seniors in New York are encouraged to remain in their home as they age with community Medicaid programs. Seniors are required by the MLTC program to apply for a Managed Care Plan through the Local Department of Social Services.

The Managed Care Plan provides recipients of Medicaid with a large number of Home and Community-Based Services (HCBS) which includes care through home health agencies and nursing home care, treatment in psychiatric hospitals, personal care, transportation to medical appointments, including car mileage and public transportation, preventive health, treatment and dental care and an array of other types of health care. Along with the HCBS providers, New York has a concentrated network of nursing homes consisting of close to 700 facilities across the state.

Other Medicaid Programs

New York’s MLTC programs do not entirely cover the cost of an assisted living facility, but there are a number of assisted living programs) falling under Medicaid. However, the wait-lists for these programs are typically very long, and the programs’ terms of eligibility are a lot more stringent when compared to the MLTC program.

Pooled Income Trusts

One of the unique features of Medicaid eligibility rules in New York is the use of a Pooled Income Trust for eligibility. Unlike a Qualified Income Trust or Miller Trust used in other states, the Pooled Income Trust allows you to place monthly income that is above the state limit into an account that is managed by a company that holds the excess income of multiple individuals which helps with eligibility for Medicaid. This income can be put to use for your Medicaid expenses and cost of care.

Applying for Medicaid in New York

Applying for Medicaid in New York is a simple process. All you have to do is submit a Medicaid Application on the Internet, or you can submit a paper application which is available on the state website. If you need assistance with applying for Medicaid in New York, all you have to do is visit this website.

Overview of the Medicaid Eligibility Program

Medicaid in New York pays for the cost of nursing home care that meets certain health and financial criteria. The average cost of skilled nursing care in the state is $131,856, which makes it essential to secure Medicaid coverage. There are 624 nursing homes across the state and out of this, 98% accept Medicaid as a form of payment. Costing $1,000 a day, the most expensive nursing home in New York is Village Care Rehabilitation and Nursing Care Center, while at $98 a day, the least expensive is St. Vincent De Paul Residence. At present, nursing homes in the state are 90.44% full with 104,130 patients using the 115,134 beds that are currently available.

Medicaid Asset Limits for 2018 in New York

When applying for Medicaid for long-term care in New York, individuals are permitted to keep $15,150. If they are over this amount, they are required to spend down on care. An important thing to keep in mind is that prior to applying to Medicaid, you are not allowed to give any gifts of any amount for a period of 60 months, i.e., 5 years. If your assets exceed $15,150, you should find out more about the many Medicaid planning strategies. It is also important to note that this asset limit is only applicable for assets considered countable. A couple of examples of these assets include savings accounts, various retirement accounts, bank accounts, and also a second home. If you have a number of assets and wish to access Medicaid, you should consult either an Elder law attorney or a New York Medicaid Planner. The IRA and retirement accounts of the spouse who is institutionalized as well as the community spouse, are considered as countable and assets that cannot be exempted in New York.

In a couple, partners that both need Medicaid for long-term care are permitted to keep assets worth about $22,200. If only one spouse requires care, the spouse not receiving care is referred to as the community spouse. The community spouse can keep half of their assets up to $123,600 in countable assets – this type of asset is known as Community Spouse Resource Allowance. The community spouse can also keep their entire marital assets up to $74,820.

When applying to Medicaid, the maximum home equity amount allowed is $858,000. Although the home is not a countable asset, Medicaid can seek repayment in probate court from the sale proceeds after it stops care payment. It is important to find out if your home may be subject to the repayment process of Medicaid.

Income Limits for Medicaid in New York

New York does not have an income cap for the people receiving care. If you are married, your spouse’s income does not, in most cases, count towards the income cap. However, you should note that it is important to maximize the protection of your income through the rules of the Monthly Needs Allowance. The maximum income amount that a community spouse is allowed to kept by the Medicaid office in New York is $3,023. An individual’s entire income must be used for their cost of care, aside from the personal needs allowance of $50.

Penalty Information for Medicaid in New York

If an individual gives a gift of any amount during a period of 5 years prior to applying to Medicaid, there will be a penalty period. In New York, this penalty period is known as a look-back period, and it can make an individual lose their eligibility for Medicaid. Care will not be paid for by Medicaid until the penalty period is over.

  • Central - $8,768
  • Northern Metropolitan - $11,455
  • New York City - $11,843
  • Long Island - $12,390
  • Rochester - $10,660
  • Northeastern - $9,414
  • Western - $9,442

The average cost of nursing home care in the state of New York is $11,330. This is why when a family does not properly plan for Medicaid, penalties can become extremely costly. Gifts can lead to a penalty period, and delay Medicaid benefits. During this penalty, anyone who has transferred assets will not be eligible for help and benefits from Medicaid that calculates the period of penalty by dividing the amount that is transferred by the penalty divisor which is the average private pay cost of care center or nursing home in the state. This penalty divisor tends to vary from state to state and also increases over time. Thankfully, this number does not increase as quickly as average nursing home costs.

Long-Term Care Partnership in New York

As part of the Deficit Reduction Act (DRA) signed on February 8, 2006, an individual may have the eligibility to apply for larger asset exclusion than those listed above. If the long-term care policy that an individual purchased qualifies as a “Partnership Qualified,” or PQ, policy, then Medicaid will use exempt assets to match the policy “dollar for dollar.” This means that if the payout of a policy is $150,000, Medicaid will provide asset exclusion up to that amount.

Types of Long-Term Care Plans in New York

Managed Long-Term Care (MLTC) is a system that provides nursing home and home health services and other long-term care services for recipients of Medicaid through private companies. Medicaid funds in the state of New York are used to hire managed care companies to provide long-term care services to recipients. An increasing number of Medicaid recipients are being transitioned by the state to managed care programs. In New York City and a large number of other areas in the state, if you are over the age of 21, have Medicare as well as Medicaid and are in need of long-term care services, enrolling in a managed long-term care program is a must.

In New York, there are two basic types of long-term care plans: Managed Long-Term Care (MLTC) Plans and Program for All-Inclusive Care for the Elderly (PACE) Plans. With MLTC Plans, you get coverage for long-term care services as well as other health services such as medical equipment, prescriptions, and dentistry. Participants of MLTC Plans select primary care providers and make payments with their Medicaid and Medicare benefits. On the other hand, participants of PACE Plans receive their services from a team of professionals such as doctors, nurses as well as social workers, whose role is to provide coordination of individualized care. Participants of PACE must be a minimum of 55 years of age and receiving Medicaid.

Supplemental Security Income (SSI)

The Supplemental Security Income (SSI) is a program that makes benefit payments to disabled children and adults with limited income and resources. SSI benefits are also paid to individuals who are aged 65 and over without disabilities who meet the financial limits. Disabled people who are approved for SSI benefits will receive Medicaid.

Apart from the age of eligibility and disability, you must have no income, or a low income and few resources to qualify for SSI. This means that the value of the items you own must be below $2,000 if you are single and below $3,000 if you are married. The value of the home you live in does not count, and in most cases, neither does the value of your car. Additionally, the value of certain resources, like a burial plot, is also unlikely to count. To receive SSI, you must also apply for any other cash benefits that you may be able to receive. You must also be a citizen of the United States or the Northern Mariana Islands. If you are not a citizen of the U.S., but lawfully residing in the country, you may still be able to receive SSI.

The state of New York makes monetary additions to the federal payment. It may consider the borough or county you reside in when it is determining the amount that is appropriate to supplement your payments towards SSI. Additionally, the state also considers whether you reside in adult foster care or group home, also known as congregate care when determining the amount to supplement your SSI payments. Both the federal SSI payment and the supplement you receive from the state of New York is included in the single payment that you will get at the start of every month.

Eligibility Criteria for SSI and Medicaid

It is heartening to state that thirty-two states in the United States, including the state of New York, and also the District of Columbia provide eligibility for Medicaid to individuals who are indeed eligible for SSI benefits. The eligibility for Medicaid starts in the same months as eligibility for SSI. And, the application for SSI is also the application for Medicaid in these states.

If the state of a recipient provides Medicaid to individuals on SSI, he or she will continue to be eligible for Medicaid. Coverage from Medicaid can continue even if the earnings of a recipient, combined with other earnings become too high for a cash payment for SSI.

To qualify, a recipient must:

  • Have been eligible for an SSI cash payment for a minimum of one month;
  • Be aged, blind or disabled;
  • Meet all other rules for eligibility, including the income and resources tests;
  • Require Medicaid to work;
  • Have gross earned income that is not enough to replace Medicaid, SSI and any attendant care that is publicly funded.

If an individual exceeds the income and/or resource test, he or she will lose the eligibility for SSI and in turn, his or her SSI-related Medicaid benefits. It is, therefore, extremely important to know how to reduce income counted toward the income test as well as how to ensure that resources are kept below the statutory limit.

In the state of New York, SSI recipients automatically qualify for Medicaid. As mentioned earlier, Medicaid is a health insurance program that is designed for individuals with limited income and resources, providing comprehensive health care at no cost. Paying as little as $1 for SSI allows the Medicaid benefits of an individual remain intact. It is due to this reason that maintaining eligibility for SSI plays a critical role in ensuring that an individual continues to receive comprehensive health coverage.

Long-Term Care Partnership Program

The Long-Term Care Partnership Program is a state-operated initiative supported by the federal government that allows individuals who purchase a qualified long-term care insurance policy or coverage for the protection of their assets that would be typically required to be spent down before they qualify for Medicaid coverage.

Once a Partnership policy is purchased, and the individual uses a portion or all of the benefits of the policy, the amount of used policy benefits will not be regarded or considered for purposes of calculating how eligible the individual is for Medicaid. In layman terms, this means that he or she can keep his or her assets only up to the amount of the policy benefits paid under the coverage or policy. For example, in a state that chooses to be a participant of the Long-term Care Partnership Program, once you have used a portion or your entire maximum lifetime benefit (MLB), you would get protection for your assets up to the amount you paid under the policy. It would not be necessary for you to spend those assets prior to qualifying for Medicaid in that state.

In 1993, the New York State Partnership for Long-Term Care was initiated in the state as a means to encourage more people to buy insurance policies for long-term care. In this program, if you buy a long-term care policy that is approved and meet certain other requirements, you can obtain Medicaid coverage after exhausting the benefits you receive under the long-term care policy. Qualification for the program is based on income, and you may be permitted to retain a portion of or your entire assets – this depends on the policy you purchase.

To purchase a long-term care policy that is approved by the New York State Partnership for Long-Term Care, an applicant is required to meet all of the insurance company’s underwriting rules. When you have nearly exhausted the benefits under the policy, you or your representative must file an application for Medicaid.

If you are considering buying a New York State Partnership long-term care policy, but intend to move out of state, the benefits you receive under the policy will still be payable. The asset protection under the New York State Medicaid Program is only applicable if you are a resident of the state of New York. Asset protection under other states’ Medicaid and Partnership programs (if any) may be available to those insured by the New York State Partnership policy if the other state participates in the reciprocity of Medicaid when the individual insured by the New York State Partnership policy applies for Medicaid in that state. It is important to keep in mind to carefully consult the documents that are issued with your New York State Partnership coverage that concerns reciprocity of Medicaid and all other matters.

Medicaid in the Medically Needy States

There are individuals who satisfy the categorical eligibility requirements of Medicaid, such as being over the age of 65, disabled or pregnant but do not satisfy the requirements for financial eligibility because their income is too high to qualify for Medicaid. In certain states, those individuals may still be able to qualify for the program if their medical expenses are significantly high, reducing their income below a certain level, through what is known as “medically needy” programs. All states in the United States have the option of covering individuals who are considered medically needy, but not all do.

States with medically needy programs, like New York, may choose not to offer the medically needy option to all categories of individuals eligible for Medicaid. For instance, a few states may opt to offer the coverage to only the elderly, but not to disabled individuals. However, states offering any medically needy programs are required to provide them to the majority of children and pregnant women.

How Medically Needy Programs Work

If your state offers a medically needy program, you can use medical expenses that you incur to “spend down” or lower your income to become eligible for Medicaid. During a state-established spend-down period, during which your income and expenses are looked at to determine if you qualify for coverage. After every spend-down period, you will be required to re-qualify for Medicaid. These periods range from 1 to 6 months. Let us explain this to you through an example. Assuming your county or state has a stipulated spend-down period of six months, then you will be required to establish that you have sufficient medical expenses within the 6 months in order to reduce your earnings below the limit of the medically needy income. Once you are able to show that you indeed have sufficient expenses and cannot cover your medical expenses on your own, you become eligible for Medicaid for the remaining of the 6 months. After the 6 months, you will need to establish this spend-down all over again.

You should note that there is no need to show that you did pay up the medical expenses in order to meet the requirements of your spend-down. All you have to do is show that you did incur the expenses. The types of expenses that are allowed vary from state to state. However, most states do consider and give credit for Medicare and similar health premiums.

Medically Needy Income Limits (MNIL) vary from state to state based on the number of people in the household. In some states, MNILs also vary based on the cost of living in different regions of the state. MNILs, in any case, is very low and unless your medical expenses are significantly higher, they can be quite difficult to meet. In most cases, MNILs are well below the federal poverty level, and they can be as low as a couple of hundred dollars a month.

In some states, you can opt to make payments directly to the state for your spend-down amount, rather than showing proof of the medical expenses you incurred. Called a “pay-in spend-down,” this particular option is real a boon for individuals who require the coverage provided by Medicaid but might have the required amount of medical expenses in a certain window of time in order to maintain the required eligibility for the coverage. The pay-in spend-down option is not offered in all the states that have medically needy programs in place. A few states that have this option are New York, Missouri, and Illinois.

Medicaid Expansion and the Medically Needy

In some states, Medicaid is expanded under the Affordable Care Act to low-income adults who are aged below 65. In the states with Medicaid expansion, some individuals who might have previously been eligible for aid under a medically needy program will now find it a lot easier to qualify under the Medicaid expansion terms of the state. However, the expansion of Medicaid does not have an effect on those individuals who are aged 65 or older. Due to the fact that significant medical expenses are often incurred by the elderly in the form of long-term care costs, medically needy programs continue to play an important role for them in the medical care that they receive.

Should You Apply for Medicare?

As mentioned earlier, Medicaid provides health coverage for low-income adults, elderly adults, pregnant women, children and people with disabilities. It is administered by the state, according to the requirements set by the federal government. The program is funded by the federal government and the states.

On the other hand, Medicare is a federal health insurance program that is designed for:

  • Individuals aged 65 or over
  • Individuals who are under 65 and have some kind of disabilities
  • Individuals of all ages who may be suffering from permanent kidney failure that may need dialysis or in some cases a kidney transplant, or even End-Stage Renal Disease (ESRD)

If you have Medicaid and are eligible for Medicare based on any of the criteria mentioned above, you must apply, or you risk losing the coverage you receive from Medicaid.

Medicaid has many benefits so if you have not already done so; you should apply for the program. You can apply for Medicaid via phone, post or visit your local department of social services. You may also apply on the Internet through the New York State of Health website. For more information, you can visit the New York Medicaid website.