Is Home Care Covered by Medicaid?

Getting Medicaid to Cover Home Care in New York

For the vast majority of New Yorkers, there is no place like home. The desire to age in place—to remain in the comfort and familiarity of one’s own surroundings, surrounded by a lifetime of memories—is a deeply held and universal wish. However, as we or our loved ones grow older, the need for assistance with daily life can become a reality. The cost of private home care in New York can be staggering, easily exceeding $25-$35 per hour. For a person needing several hours of care per day, this can quickly deplete a lifetime of savings, threatening the financial security of the entire family.

This reality leads to one of the most critical questions in elder law today: “Is home care covered by Medicaid?” The answer is a resounding yes, but it comes with a significant “but.” New York’s Medicaid program offers extensive home care benefits that can provide the support needed to age in place safely and with dignity. However, accessing these benefits requires navigating a complex and often confusing system of financial and medical eligibility rules. At Morgan Legal Group, we have spent decades guiding families through this maze. In this comprehensive guide, we will demystify the process, explaining how Medicaid home care works, who is eligible, and—most importantly—how proactive planning can allow you to protect your life savings while getting the quality care you deserve at home.

The First Step: Understanding Medicaid vs. Medicare

Before diving into the specifics of home care, it is absolutely essential to understand the fundamental difference between the two government programs that sound confusingly similar: Medicaid and Medicare. This is the single most common point of confusion for families, and misunderstanding this distinction can lead to costly planning mistakes. They are two completely different programs with different purposes, funding sources, and rules.

Think of it this way: Medicare is a health insurance program you have earned, while Medicaid is a needs-based safety net. One offers very little help with long-term care, while the other is the primary payer for it in the United States. Grasping this difference is the bedrock of any sound long-term care plan. Our founder, Russel Morgan, Esq., has always emphasized that client education is the first step toward empowerment.

What is Medicare? Your Federal Health Insurance

Medicare is a federal health insurance program primarily for individuals aged 65 and older, as well as for some younger people with certain disabilities. You have paid into the Medicare system throughout your working life via payroll taxes. It is an entitlement program, meaning if you are eligible, you receive benefits regardless of your income or assets.

Medicare is excellent for what it is designed to do: cover acute medical needs. This includes:

• Hospital stays (Part A)
• Doctor’s visits and outpatient services (Part B)
• Prescription drugs (Part D)

However, Medicare’s coverage for long-term care—the ongoing assistance with daily life that most seniors eventually need—is extremely limited and often misunderstood.

Medicare’s Limited Home Care Benefit

Medicare does have a “home health care” benefit, but it is not long-term care. Medicare’s benefit is designed for short-term, rehabilitative care following an illness or injury. To qualify, you must be certified as “homebound” and in need of “intermittent skilled nursing care” or therapy services. The care must be prescribed by a doctor as part of a formal plan of care.

What this means in practice is that Medicare might cover a visiting nurse for a few weeks after a hospital stay to change a dressing or a physical therapist to help you regain mobility. It does not cover what most people think of as home care: assistance with “custodial” tasks like bathing, dressing, eating, and medication reminders. This type of ongoing support is what Medicaid is designed to cover.

What is Medicaid? The Safety Net for Long-Term Care

Medicaid, in contrast, is a joint federal and state program designed to provide health coverage to low-income individuals of all ages. It is a needs-based program, meaning you must meet strict financial eligibility requirements related to your income and assets. While it provides general health coverage, its most critical role for seniors is as the nation’s primary payer for long-term care services.

This includes both institutional care (nursing homes) and, importantly for our discussion, a wide range of home and community-based services. For families in New York facing the potential for years of expensive care, understanding and planning for Medicaid eligibility is the key to preserving their financial legacy. The focus of a good NYC elder law practice is to help clients navigate this system.

New York Medicaid Home Care Programs: Your Options for Aging in Place

New York has a robust system of Medicaid-funded home care programs designed to provide an alternative to nursing home placement and allow individuals to remain in their communities. These programs fall under the umbrella of what is often called “Community Medicaid.” They offer a spectrum of services, from basic assistance with daily tasks to more advanced skilled care, all delivered in the comfort of your own home.

Personal Care Services (PCS)

This is the most common type of Medicaid home care. Personal Care Services provide assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). An aide can help with tasks such as:

• Bathing, dressing, and grooming
• Walking and transferring from a bed to a chair
• Toileting and incontinence care
• Preparing meals and feeding
• Light housekeeping and laundry
• Shopping and running errands
• Medication reminders

The number of hours of care approved is based on a medical assessment of the individual’s needs. For those with significant needs, it is possible to be approved for 24-hour care, often on a split-shift basis.

The Consumer Directed Personal Assistance Program (CDPAP)

CDPAP is a revolutionary and highly popular program in New York that offers consumers incredible flexibility and control. Under the traditional model, a home care agency selects, trains, and sends an aide to your home. Under CDPAP, the Medicaid recipient (or their designated representative) is empowered to recruit, hire, train, and supervise their own caregivers.

The key advantage is that you can hire almost anyone you trust to be your caregiver, including most family members (spouses are the main exception), friends, or neighbors. This allows you to be cared for by someone you know and are comfortable with. The caregiver is then paid through a fiscal intermediary, an agency that handles the payroll and benefits using Medicaid funds. CDPAP is an excellent option for those who want to direct their own care and have a trusted person they want to hire. For more information, you can always get in touch with our knowledgeable team.

Managed Long-Term Care (MLTC) Plans

In most parts of New York, including all of New York City, Medicaid home care services are delivered through Managed Long-Term Care (MLTC) plans. Once you are approved for Community Medicaid and are found to need more than 120 days of long-term care, you must enroll in an MLTC plan.

An MLTC plan is a type of private health insurance plan that has a contract with the state to provide and coordinate all of your long-term care services. You will be assigned a care manager who works with you and your family to develop a plan of care. The MLTC plan is responsible for authorizing the type and amount of services you receive, including home health aides, CDPAP, nursing visits, and therapies. Choosing the right MLTC plan is an important part of the process, and an experienced attorney can help you understand the options.

The Critical Question: Am I Eligible for Medicaid Home Care in New York?

This is the heart of the matter. To qualify for Community Medicaid to cover home care, you must meet two distinct sets of criteria: medical eligibility and financial eligibility. Both must be satisfied. You can be the sickest person in the world, but if your income or assets are over the limit, you will be denied. Conversely, you can be impoverished, but if you are not deemed to need the level of care Medicaid provides, you will also be denied. Navigating these dual requirements is where professional guidance is most valuable.

Part 1: Medical Eligibility – Proving the Need for Care

To be medically eligible for Medicaid home care, you must demonstrate a need for assistance with your Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs). The state needs to be convinced that without this help, you would be at risk of needing to enter a nursing home.

The assessment process typically involves two key steps:

1. The Independent Assessor: A nurse from the New York Independent Assessor (NYIA) program will conduct an initial telehealth assessment to determine if you are medically eligible for long-term care services.
2. The MLTC Plan Assessment: Once you choose an MLTC plan, a nurse from that plan will conduct a more detailed, in-person assessment in your home. This assessment will determine the specific types and number of hours of care they will authorize in your plan of care.

It is crucial to be honest and thorough during these assessments. You and your family should be prepared to discuss all the ways in which you need help, from bathing and dressing to managing medications and preparing meals. Understating your needs can result in an inadequate care plan.

Part 2: Financial Eligibility – The Income and Asset Rules

This is the area where most families run into trouble and where proactive planning is essential. To be eligible for Medicaid, your monthly income and total countable assets must be below strict, state-mandated limits. These limits change annually. The figures below are for 2024 and are provided for illustrative purposes. For the most current figures, you should consult an experienced elder law attorney or the official New York State Department of Health website.

The 2024 Income Limits

For Community Medicaid in 2024, the monthly income limit is:

• $1,732 for a single individual
• $2,351 for a married couple

What if your income is over the limit? Thankfully, New York is an income “spend-down” state. This means that if your income exceeds the limit, you are not automatically disqualified. You can become eligible by spending the excess income on your medical costs each month. The most common and effective way to do this is by enrolling in a “pooled income trust.” You deposit your surplus income into the trust each month, and the trust then pays your household bills (like rent, utilities, and food) for you. This allows you to use your income to live on while still qualifying for Medicaid.

The 2024 Asset Limits

The countable asset limit for Community Medicaid in 2024 is:

• $31,175 for a single individual
• $42,312 for a married couple

“Countable assets” include things like cash in bank accounts, stocks, bonds, and real estate other than your primary home. Certain assets are exempt, including:

• Your primary residence (up to an equity limit of $1,071,000 in 2024)
• One automobile
• A pre-paid, irrevocable burial fund
• Personal belongings and household goods

The Looming Threat: The 30-Month Look-Back Period

For decades, there was a key difference between applying for Medicaid for nursing home care and for home care. The nursing home application came with a five-year “look-back” period, where Medicaid scrutinized all your financial transactions for the past five years. The home care application had no look-back period. This has changed.

New York is currently phasing in a 30-month (2.5-year) look-back period for Community Medicaid applications. This means that when you apply for home care, Medicaid will look at all the assets you have transferred or given away in the 30 months prior to your application. If you have made gifts or uncompensated transfers during that period, Medicaid will impose a “penalty period”—a period of time during which you will be ineligible for benefits, even if you meet all the other criteria. This new rule makes proactive planning more important than ever. You cannot simply give your assets to your children and apply for Medicaid the next day. This is a critical aspect of estate planning that requires professional guidance.

The Solution: Proactive Medicaid Asset Protection Planning

After reviewing the strict financial eligibility rules, many people feel a sense of hopelessness. They think, “I have worked my whole life to save this money and buy this home. Am I going to have to lose it all to get the care I need?” The answer is a definitive no. You do not have to be poor to qualify for Medicaid. You simply have to have a plan. Proactive Medicaid planning is a well-established area of law that allows you to legally and ethically restructure your assets so that you can qualify for benefits while preserving your life savings for your family.

The Cornerstone of Planning: The Medicaid Asset Protection Trust (MAPT)

The single most powerful tool for Medicaid planning is the Medicaid Asset Protection Trust (MAPT). This is a special type of irrevocable trust that is specifically designed to protect your assets, particularly your home, from being counted for Medicaid eligibility purposes.

How a MAPT Works

1. You work with an experienced elder law attorney to draft the MAPT document. You will name a trusted person, often an adult child, to act as the trustee.
2. You transfer your major assets, like your home and any non-retirement investments, into the trust. This starts the 30-month look-back clock.
3. You retain certain rights. For your home, you can retain the right to live in it for the rest of your life. You also retain any property tax exemptions you may have, like STAR or Veterans benefits.
4. You can continue to receive all the income generated by the trust assets (like dividends or interest). You just cannot access the principal of the trust.
5. After the 30-month look-back period has passed, the assets inside the trust are completely protected. They are no longer considered “yours” for Medicaid eligibility purposes. You can then apply for Medicaid home care without those assets being counted against you.

A MAPT is the key to preserving your legacy. It allows you to get the care you need at home, paid for by Medicaid, while ensuring your home and savings pass to your children as you intended. This is a vital strategy, especially in cases where families are concerned about potential elder abuse and financial exploitation of a vulnerable senior.

What If I Need Care Now? Crisis Planning Strategies

What if you or a loved one needs home care immediately and has not done any advance planning? Is it too late? While proactive planning is always better, it is almost never too late to take action. An experienced elder law attorney has a toolkit of “crisis” planning strategies that can help you qualify for Medicaid as quickly as possible while still protecting a significant portion of your assets.

These strategies are more complex and might involve purchasing a special type of annuity, strategically spending down assets on exempt items, or utilizing spousal refusal rules (in the case of a married couple). The key takeaway is this: do not assume it is too late and do not try to navigate a crisis situation on your own. You should immediately contact an elder law attorney to explore your options.

The Application Process: A Marathon, Not a Sprint

Applying for Community Medicaid in New York is a long and arduous process. The application itself is lengthy, and the amount of required documentation is staggering. It is not uncommon for the process, from start to finish, to take six months or longer. Attempting to do this without professional guidance often leads to frustrating delays and costly denials.

Here is a general overview of the steps involved:

1. Consultation and Planning: The first step should always be to meet with an elder law attorney to create a plan.
2. Document Gathering: You will need to gather extensive financial records, often for the full look-back period. This includes bank statements, investment records, property deeds, and proof of income.
3. Filing the Application: The completed application and all supporting documents are filed with your local Department of Social Services (in NYC, this is the Human Resources Administration or HRA).
4. The Medical Assessment: As described earlier, the independent assessor will conduct a telehealth evaluation.
5. Choosing an MLTC Plan: Once you are deemed eligible, you will need to select and enroll in a Managed Long-Term Care plan.
6. The Plan of Care: The MLTC plan’s nurse will visit you at home to conduct their own assessment and develop your final plan of care, which outlines the services and hours you will receive.

Navigating this multi-stage process requires patience, organization, and a deep understanding of the system. Our team at Morgan Legal Group handles this entire process for our clients, from the initial planning to the final approval of care.

Conclusion: Securing Your Care, Protecting Your Legacy

The ability to age in place, in the comfort of your own home, is a priceless gift. In New York, Medicaid provides a pathway to make this a reality, offering comprehensive home care services that can provide the support you need. However, accessing these benefits requires a clear understanding of the complex financial and medical eligibility rules. It is not a system designed for the average person to navigate alone.

The most important takeaway is that you have options. You do not need to spend down your life savings to get the care you need. Through proactive Medicaid asset protection planning, particularly with the use of a Medicaid Asset Protection Trust, you can legally and ethically protect your home and your savings for your family while qualifying for the benefits you are entitled to. The key is to plan ahead. With the new 30-month look-back period for home care, the time to start planning is now.

At Morgan Legal Group, we are passionate about helping New York families navigate these challenges. We believe everyone deserves to age with dignity and security. We provide the expert guidance and compassionate counsel you need to create a plan that protects your health, your home, and your legacy.

Do not wait until you are in a crisis. Take control of your future today. Contact Morgan Legal Group to speak with our experienced elder law team, or schedule a comprehensive consultation and let us help you secure the peace of mind you and your family deserve.

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