Community (Home-Care) Medicaid

heCommunity (Home-Care) in New York

Serving Clients in New York City and New York Metropolitan area


Introduction

Living safely and comfortably at home for as long as long as possible is a common desire our clients share. Our firm understands this and works with elders and their families to accomplish this goal

Often, successfully aging at home requires the help of others. When facing the frailties of old age, a long-term or serious illness or the onset of a form of dementia, the need for care in the home is very real. The current focus of the health care system is to favour home health care and in-home services. When a member of a family becomes seriously debilitated the family frequently marshals their funds and energy to provide the initial levels of care needed, which can be draining to a family over time. The high costs of the long-term care impacts the family’s savings and curtails the ability to continue to privately provide or pay for care.

Soon, families exhausted by the demands of caring for their elders seek government or social services assistance. Caregivers will discover that the system is not so easy to understand. Home care services that are needed may be covered by a variety of sources, such as from private medical insurance, Medicare for those who are over 65 or disabled, or by Medicaid for those with lower income, or are aged, blind or disabled. The rules of these programs are different, confusing and complex. Professional guidance in navigating the home care system soon becomes a necessity. The Grimaldi & Yeung Law Group provides this necessary guidance and support to our clients who want to be cared for at home. We can develop a care plan with the appropriate financing options that make sense for you.

Care At-Home Options

Community and Local Sponsored Options

At the onset of an illness, most individuals either rely on their private health insurance to cover short- term rehabilitation and curative care to get them back to health, or they look to local social services agencies for help. They may find an informal network of home health aides or the services of licensed home care agencies that will work on a fee-for-service basis. In addition, private insurance coverage may provide a few weeks of interim benefits, but often personal savings are tapped or depleted. At this point many individuals look for a government benefit to fill the need. The following publicly funded home care options are available

NYS Expanded In-Home Services for the Elderly Program (“EISEP”)

The EISEP program is designed for low-income seniors who do not qualify for Medicaid. This program provides seniors with in-home non-medical care services and case management. The goal is to prevent or delay the placement of the frail elderly into more expensive Medicaid funded nursing homes. In providing in-home services to seniors and their caregivers, the State hopes both to contain costs and to provide the aged and disabled with the least restrictive form of care. Under EISEP, in some areas of New York adult children or other relatives can work as paid caregivers to their elderly parents or family members. These services are billed to the senior in need on a sliding scale and are modestly priced and are subsidized by state funds, but are not entirely free.

In 2011, changes were made to the program to allow for consumer direction of in-home care services (referred to as CDIS). Consumer direction empowers the care recipient to select, train and manage their own care providers instead of the state doing that on their behalf. Participants are able to hire other family members and pay them (with the state’s money) for their caregiving services, provided they meet the program’s requirements. Consumer direction varies from county to county; one should inquire with their local Area Agency on Aging to see about availability.

EISEP services and other local city and county benefits for the aged are available through the County’s Area Agency on Aging. In New York City this agency is the NYC Department for the Aging, which will assess the individual in the home and develop a full plan of care including home maker services, friendly visiting, shopping services and Meals On Wheels. The services are limited to a few hours two to three times a week and there is a sliding scale contribution assessed for each service. (See, https://aging.ny.gov/expanded-home-services-elderly-eisep).

EISIP Program participants must be (a) home bound, and (b) over age 60 and need assistance with their daily activities. However, their care requirements cannot be so severe that the cost of caring for them at home exceeds the cost of the same care in a nursing home. For example, individuals with early-stage Alzheimer’s would be eligible, but those in the late stages of the disease would probably require a level of care not supported by these services.

EISEP does not have fixed, published income and assets limits, although the program does have cost-sharing rules which impact those participants whose income is greater than 150% of the federal poverty level. Those whose incomes exceed the poverty limits should still pursue assistance from this program. The cost-sharing co-payment EISEP may require is very reasonable and a fraction of the cost of care on the open market. Therefore the services can be cost effective, but the level and duration of services is limited.

EISEP Benefits and Services

The services provided under EISEP may vary from county to county and with each participating individual. The fees for EISEP services are on a sliding scale determined by the participant’s income level. There can be no charge, or a co-payment may be required. If co-payments are required, they are a fraction of what the services would otherwise cost were a private home care worker hired. In addition to case management, services may include:

  • Adult Day Care
  • Assistance with the Activities of Daily Living – bathing, grooming, dressing etc.
  • Chore Services
  • Housekeeping / Homemaker Services
  • Meal preparation
  • Medication reminders
  • Personal Emergency Response Services
  • Respite Care
  • Transportation assistance or escorts

Meals On Wheels (MOW)

Those who do not want in-home assistance may still find benefit from home-delivered meals. This simple service may be the sole act that makes the difference in keeping an elder independent at home. The Meals On Wheels programs are usually offered by local not-for-profit agencies under the direction of the state and local case management services for the elderly or the local senior nutrition programs. The Meals On Wheels representative is an important community gatekeeper who can make the difference in the ability of the senior to remain at home. The nutritional benefit of a daily meal is coupled with the visit of a trained driver who often can spot an emerging health emergency or the need for an intervention.

Medicare Coverage

Original Medicare: Home Health Care Coverage Overview

Medicare is the primary health insurance of older adults and persons with disabilities. Home care services are provided under both Part A (Hospital coverage) and Part B (Community or Outpatient coverage). Part B provides part-time and intermittent home care services, usually as part of a rehabilitation plan of care. In order for Medicare to authorize home care the following criteria must be met:

  • A physician must certify the need for skilled care (such as physical therapy (PT), occupational therapy (OT), nursing visits) on a part-time or intermittent basis
  • There must be a home health care plan through which the skilled services are arranged.
  • The skilled care can be combined with non skilled personal care
  • The beneficiary must be considered to be “homebound” (someone who requires assistance when leaving the home)
  • Medicare-covered home care services must be provided by a Certified Home Health Agency (CHHA)

Medicare-Financed Home Care

Medicare services are usually provided by Certified Home Health Care Agencies (CHAAs). These agencies range from large non-profits, such as the Visiting Nurse Service of New York, to smaller more customized services affiliated with hospitals or social service agencies. CHAA services are medically focused, must be “ordered” by the treating physician, and are evaluated and supervised by registered nurses. Medicare home care services typically last 4-to-6 weeks and rarely provide more than 20 hours per week. It is intended to be rehabilitative, not long-term care.

Private Insurance and Private Pay

The largest segment of in-home care is financed by insurance or by private payment. Instead of being limited to medical needs, these services tend to focus on personal care, companionship and assistance with the activities of daily living. They usually focus on keeping individuals safe and independent at home. Services are typically, but not always, provided by licensed home care agencies. When an individual’s private insurance or Medicare coverage is fully used, individuals and caregivers can look for other solutions for the long-term in-home care needs of the disabled. If an individual’s resources or insurance are not available to cover the costs of care, private pay home care can be a solution. These services can be customized to the elder’s needs and can be more flexible in the services provided. These are purely out of pocket services which are not subsidized and not covered by LTC insurance.

Medicaid Home Care Services

What is Medicaid and why has it become the financing solution for long-term care?
Medicaid is a joint federal, state and local program which provides medical assistance to persons with low incomes and limited assets. It is available to persons who are eligible for public assistance or SSI (Supplementary Security Income.)

“Medically Needy” Medicaid
In NY State, Medicaid may also be available for persons with higher incomes through the Medicaid Surplus Income Program. New York is committed to not only provide benefits for the financially needy, but also the “medically needy” whose extensive health needs create catastrophic health care costs. This program usually available for:

  • persons over sixty five years of age
  • the blind
  • the disabled (under 65)
  • people whose incomes and resources are above the federal poverty levels

Medicaid recipients can spend their income, which may be in excess of the Medicaid income level, on non-covered medical costs and thereby reduce their countable income. Thus, an over-income individual who applies for Medicaid home care services can agree to pay their excess income to the agency providing their care as a cost-share or co-pay. This meets the requirement that their income is “spent down” on medical care. Often, the amount of excess income paid for care is well below the market fee for service ordinarily charged for the service.

As an alternative to “spending down”, New York permits Medicaid recipients living in the community and in certain congregate care facilities to protect their excess income by placing this excess income into income trusts administered by Medicaid approved not-for-profit groups. The not-for-profit trusts “pool” these individual income deposits into a managed trust fund. Upon deposit of the excess income into the pooled income trust, a Medicaid applicant will meet the income and resource eligibility thresholds.

Medicaid can cover all types of medical care, including hospital care, doctor bills, nursing home coverage, adult day care, and most importantly home care services, transportation, medical supplies, and prescriptions.

Since 2012, NYS Medicaid has moved its home care services into a Managed Care System.

Managed Long-Term Home Care

As part of New York State’s Medicaid Redesign program initiated in 2012, Personal Care services at home are no longer managed by the individual’s local social service district, such as HRA in New York City or county-based Department of Health offices. Medicaid recipients of personal care, home care and housekeeping can now enroll in a managed care program administered by a private or nonprofit service contracted by New York State’s Department of Health, called a Managed Long-Term Care Program (MLTCP).

These agencies are responsible for delivery of the following range of services:

  • Personal care
  • Adult day care
  • Emergency response systems
  • Certified home health agencies (CHHA)
  • Medical supplies
  • Hearing aids
  • Eyeglasses
  • Dental
  • Home modifications and transportation

These services are provided by the private Managed Long Term Care agencies (MLTC’s) licensed by NYS Local Social Services Districts (“LSSD”). The MLTC’s determine the care plan for all Medicaid home care recipients in New York State. The assessment process is divided into two separate, independent care assessments after financial eligibility is set.

Assessment One: Conducted by a RN under the auspices of NY State to determine if home care is an appropriate service plan.

Assessment Two: Conducted by a Managed Long Term Care agency staff RN, who determines the hours and type of services needed. Strong advocacy is needed at this meeting to insure that sufficient care is allocated. Criteria for how many hours are needed focuses on such issues as the applicant’s ability to safely ambulate, toilet and/or transfer, as well as activities of daily living, such as bathing, dressing, and meal preparation; therefore, evidence on these needs and incapacity should be provided by the treating physician, carefully documenting the reason the level of home care is needed.

Specialized home care programs available under Medicaid:

  • The Lombardi Program (Nursing Home without Walls)
  • Consumer-Directed Home Care
  • Managed Long-Term Care / TBI Waivers
  • Hospice Care

The Lombardi Program (Nursing Home without Walls/NHWW)

Individuals who need complex home care (equivalent to the care provided in a nursing home) will find it in New York’s unique Nursing Home Without Walls Program. The program provides basic home health care for approximately 20 hours per week in addition to ancillary and comprehensive services, such as skilled nursing, physical and rehabilitative therapy, transportation to medical appointments, nutrition counselling, home adaptations and equipment, and other specialized support, activities and options. Certified Home Health Agencies (CHAA’s) manage these Lombardi programs. This program is useful as it can accommodate individuals with higher levels of medical needs, as skilled and nursing services are well integrated into the care plan.

Consumer-Directed Medicaid Home Care

People living with disabilities and their families have long advocated for greater autonomy in developing a plan for the care at home. In response to this, Medicaid permits capable recipients to recruit and hire their own home care workers as part of a program called Consumer Directed Personal Assistance Program (CDPAP). Under CDPAP, the hired worker must have the legal right to work in the United States, have the proper training and certifications, be in good health, and accept the pay scale offered by the Medicaid agency. This is a joint effort between the Medicaid agency, which provides funding, and the Medicaid recipient, who provides administration (recruiting, hiring and replacing home care workers, in addition to submitting weekly time sheets). CDPAP provides both flexibility and autonomy for persons with disabilities and their families and caregivers. More information on CDPAP can be found here

The Nursing Home Transition and Diversion Medicaid Waiver

 The Nursing Home Transition and Diversion (NHTD) Medicaid Waiver is a Home and Community Based Services (HCBS) program, administered by the New York State Department of Health (DOH). The NHTD waiver uses Medicaid funding to provide supports and services to assist individuals with disabilities and seniors that either reside in or are medically eligible to reside in a nursing home.  The program emphasizes a person-centered, Individual Service Plan developed to support living in the community.  Participants in this program either enter from a skilled nursing facility or other institution (transition), or choose to participate in the waiver to prevent institutionalization (diversion).  

To be eligible for NHTD a person must be 18 years of age or older, (with proof of physical disability if under 65 years of age) and prefer living in the community rather than a nursing facility.  A NHTD participant must be a Medicaid recipient and medically eligible for nursing facility level of care.   The participant must have or find a community living arrangement, which is sufficient to accommodate their needs and require the Waiver services to ensure their health and welfare.  NHTD provides services to seniors who suffer from cognitive impairments such as dementia and Alzheimer’s disease that are not available through existing Medicaid programs.  This program provides vital home care including “oversight and supervision,” which are often denied by Medicaid Managed Long Term Care plans.  In addition, NHTD provides community support services, counseling and therapies to enhance a participant’s quality of life in the community.

Money Follows the Person (MFP)

Money Follows the Person (MFP) is a federal grant program which was originally enacted under the Deficit Reduction Act of 2005 and further expanded through the Affordable Care Act of 2010 with the goal of ensuring individuals living in institutions have the opportunity to live in the most integrated setting and access community base services.  The MFP program provides the states with grants for programs developed by the state to assist institutionalized individuals transition from facilities to the community.   

In New York, the MFP program is coordinated and provided by New York Association for Independent Living (NYALI) through a program called Open Doors.  Any person residing in a nursing home or other facility who voices an interest in returning to the community is a candidate to receive services through the Open Doors program as long as the individual 1) has Medicaid at least 1 day before discharge, 2) is residing in an institution (nursing home, hospital, ICF) for 60 days or more, and 3) moves to a qualified setting such as house, apartment, or group home with 4 or few people.  

The Open Doors program connects the nursing home resident who expresses an interest in returning home with a Transition Specialist.  The Transition Specialist collaborates with the nursing home discharge planner to identify barriers which prevent the resident from leaving the nursing home and help link the resident to community programs that meet the resident’s needs.  These needs can include finding affordable housing and setting up supportive services at home.  Open Doors remains involved once the resident returns to the community for at least a year to make sure the transition is successful.