Updates in Medicaid – Important Changes for Home Care Benefits Coverage
By: Dana Walsh Sivak, Esq. and Samantha A. Lyons, Esq.
Since 2020, two important changes to the Medicaid program have been looming on the horizon for applicants and recipients of community-based Medicaid benefits (including home care services, coverage for care provided in assisted living “ALP” facilities, and waiver program benefits), but, until now, had not been implemented as a result of the COVID-19 public health emergency. Now, an important change is being implemented that will impact those in need of home care assistance through the Medicaid program.
What is Changing?
Under the previous eligibility criteria, in order to qualify for home care benefits through the Medicaid program, applicants were required to demonstrate a need for assistance with at least 2 activities of daily living, or, in cases where an applicant suffered from dementia or Alzheimer’s disease, at least 1 activity of daily living (whether through a third party home care agency or through CDPAP, the Consumer-Directive Personal Assistance Program, where recipients select their own caregivers, often family members).
Effective September 1, 2025, the eligibility criteria have changed.
Now, instead of requiring applicants to demonstrate a need for assistance with at least 2 activities of daily living, applicants will need to demonstrate a need for assistance with 3 or more activities of daily living.
Individuals with a certification from a doctor that they suffer from dementia or Alzheimer’s will now be eligible only if they require “supervisory assistance or cueing” (a higher level of assistance than before) with 2 or more activities of daily living. Additionally, an updated physician’s certification of dementia/Alzheimer’s diagnosis will need to be submitted each year in order to renew benefits coverage.
The “activities of daily living” used in this evaluation are limited to: bathing; grooming/personal hygiene; dressing; walking; locomotion/moving about on the same floor; transferring; toileting; bed mobility; and eating. Previously, applicants would also receive assistance with certain “instrumental activities of daily living” or housekeeping tasks, such as meal preparation, laundry, shopping, cleaning, navigating up and down stairs, travel by public transportation, using the phone, and medication management – provided that they demonstrated a need for 1 or more of the recognized “activities of daily living” listed above. Further, under the old criteria, if an applicant did not require assistance with any of the “activities of daily living”, but did require assistance with “instrumental activities of daily living,” they could receive up to 8 hours per week of personal care assistance through the “housekeeping service” (although this was only available for individuals receiving services through the local social services district or mainstream managed care plan – not through a managed long-term care organization, or MLTC).
However, effective September 1, 2025, the housekeeping program will no longer be available for new applicants; only those currently receiving these services will continue to receive this standalone assistance.
Do These Changes Apply to Everyone?
The new requirements will apply to any new applicants for community-based Medicaid benefits, while those deemed to have “legacy status” will not be subject to these rules.
Generally speaking, a person may have “legacy status” if they are already enrolled in a managed long term care organization (MLTC) or Medicaid Advantage Plus (MAP), as of August 1, 2025, or authorized to receive home care services by the local social services district or mainstream Medicaid plan prior to September 1, 2025.
It will also apply to individuals who have been assessed by the New York Independent Assessor Program during the time period of August 31, 2024 and August 31, 2025 and deemed eligible, and then enroll in an MLTC or are authorized by the local social services district or mainstream plan within one year of the assessment (because a New York Independent Assessor Program assessment is valid for one year).
There are also some rare circumstances where an individual who was scheduled or anticipated to complete their assessment prior to September 1, 2025, but, due to no fault of the applicant, did not complete the assessment in time for the September 1st cutoff, will be afforded “legacy status” on that basis, and not subject to the new requirements.
Medicaid recipients who are “grandfathered in” based on their prior enrollment and receipt of home care benefits, however, should exercise caution when making any changes to their enrollment status, such as disenrolling from one plan and enrolling into a different plan or service, as there is concern that such a change may cause the individual to lose their “legacy” status and become subject to the new eligibility criteria.
What is Not Changing?
The previously announced, but long-delayed implementation of the 30-month look back period for applicants for community-based services Medicaid coverage will not be implemented at this time. There is no currently scheduled date for the implementation of this change, and advance notice will have to be provided before this change will take effect. As of now, there continues to be no look back period for those seeking Medicaid benefits for home care (whether personal care services or through CDPAP), waiver programs (such as NHTD or TBI waiver recipients), or assisted living facility benefits through ALP (“Assisted Living Program”).
This means that many Medicaid planning options remain available for those who may require these Medicaid-covered services for the foreseeable future – but, for how long, we cannot say.
If you or a loved one need guidance navigating these new Medicaid eligibility requirements or planning for home care benefits, contact FRB’s Elder Law Practice Group at (516) 599-0888 or complete the form below.
DISCLAIMER: This summary is not legal advice and does not create any attorney-client relationship. This summary does not provide a definitive legal opinion for any factual situation. Before the firm can provide legal advice or opinion to any person or entity, the specific facts at issue must be reviewed by the firm. Before an attorney-client relationship is formed, the firm must have a signed engagement letter with a client setting forth the Firm’s scope and terms of representation. The information contained herein is based upon the law at the time of publication.