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Medicaid Assisted Living Programs (ALP) in NYS

Views: 84769
Posted: 02 Feb, 2011
by Valerie Bogart (New York Legal Assistance Group)
Updated: 22 Mar, 2017
by Valerie Bogart (New York Legal Assistance Group)

INTRODUCTION 

The Assisted Living Program provides supportive housing and home care services to individuals who are medically eligible for placement in a nursing facility but, whose needs can be met in a less restrictive and lower cost residential setting. he operator of the assisted living program is responsible for providing or arranging for resident services that must include room, board, housekeeping, supervision, personal care, case management and home health services.

While private payment is possible, for people who meet the financial and other eligibility criteria, payment is made through a combination of:

  • Medicaid -- (or private long term care insurance or private pay) for the aide and other health care  services

  • Supplemental Security Income (SSI) Congregate Care Level III (or private pay) -- for the residential services  (room and board) (2016 figures below).

DIFFERENCE BETWEEN ASSISTED LIVING PROGRAM (ALP) and OTHER ASSISTED LIVING RESIDENCES (ALR) or FACILITIES (ALF) -

Only official licensed ALPs accept Medicaid and SSI to pay the fees.   Most Assisted Living Facilities, on the other hand, solely accept private payment for their residential services.  In such facilities, however, it is possible to apply for regular community Medicaid and to receive Medicaid personal care services, which are provided independently, having nothing to do with the ALF facility.

State law enacted in 2004 to require licensure for "ALF" facilities does NOT apply to ALPs.  This has been criticized by the Long Term Care Community Coalition because protections for ALFs do not apply to ALPs -- all the more necessary as the state expands the growth of ALPs - see below.   See  Long Term Care Community Coalition,  Vulnerable and Unprotected: The Status of Elderly & Disabled Assisted Living Residents in New York State  (Spring 2010)  posted on  http://www.assisted-living411.org/nyassistedliving.php

Laws and Regulations:

ALP  STATUTE and REGULATIONS  NY Social Services Law  Section 461-L and 367-h (for Medicaid Assisted Living Program)

                   REGULATION:  18 NYCRR 505.35, 18 NYCRR Part 494

ALR STATUTE  & regulations (Private Assisted Living, not paid by SSI or Medicaid) - Social Services Law  Sections 4650 et seq. (Article 46) and regulations  (10 NYCRR Sec. 1001 et seq. )

ALP ADMINISTRATIVE DIRECTIVES:

  • GIS 10 OLTC/008, Assisted Living Program (ALP) Model Contract (for use outside of NYC) 

          ATTACHMENT:   Model Contract

WHERE ARE ALP FACILITIES?

SEE  online list of ALP facilities on the State Department of Health website, (filter by COUNTY, and make sure column "ASSISTED LIVING PROGRAM BEDS"  is NOT ZERO)

-- 10,159 ALP beds in 136 facilities in 40 counties plus all 5 boroughs of NYC (about one-third of all counties still have no ALP beds).  .  

-- This list shows contact and address information for each facility and the number of ALP beds. 

In June 2008, the State announced a 40% increase in the number of ALP beds, adding 1,584 beds to the existing under 4000 beds -- the largest increase in more than a decade. (See announcement with lIst of facilities with number of new beds in 20 counties plus NYC -- 422 of the new beds were in the 5 boroughs of NYC).

A 5-YEAR ALP INITIATIVE to add 6000 ALP beds between April 2009 - April 2014 began pursuant to 2009 budget legislation, which was amended and continued in 2012.  Chapter 58 of the Laws of 2009 and Chapter 56 of the Laws of 2012 amended Section 461-l of the Social Services Law (SSL) to authorize the Commissioner of Health to establish up to 6,000 new Assisted Living Program (ALP) beds. The 2009  amendment required that an equal number of Nursing Home beds be decertified for all new ALP beds authorized, but this was repealed in 2012.  Information about the 2009 phase is posted here, and the 2012 phase is posted here.

  • YEARS 1 - 2 -- DOH states resulted in approval of 1,282 new ALP beds and the planned decertification of 844 RHCF beds. The first beds approved in this initiative were announced in August 2010, with 400 new beds approved in 10 counties, of which 200 beds were in NYC (4 boroughs outside of Manhattan). n November 2010 nine "HEAL 29 " grants were announced that will result in decertification of 292 nursing home beds and creation of new ALP beds and other long-term care services in 8 counties once construction is completed.  See announcement.

  • YEARS 3 - 5 - Applications due July 2012.  Info  posted here.


See the DOH online map showing ALP facilities in each county in NYS, along with private Assisted Living Residences, Enriched Housing, Adult Homes, and other residences.   Listing of terminology used in map. 

PAYMENT for ALP - has TWO PARTS:

1.  MEDICAID - for nursing/aide services - Facility is responsible for arranging and paying for out of its rate.  Resident may not separately be approved for Medicaid home care services outside of this inclusive rate.

  • Eligibility -- ALPs are considered community-based facilities.  Community eligibility is used, meaning that there are no penalties on transfers of assets and community budgeting is used, not institutional.  The income limit, however, is the same limit used for SSI Congregate Care Level III (see link in the SSI section below) (for 2017 it's $1,429/mo. instead of regular Medicaid limit of $825/mo.).  See 16-INF-18 Attachment 1 – SSI and SSP Benefit Levels Chart Effective January 1, 2017   

  • Payment  -- Medicaid rates paid to ALPs  are posted online at   https://www.health.ny.gov/facilities/long_term_care/reimbursement/alp/    Generally, Medicaid pays the facility at the rate of 50% of the rate that would be applicable if the resident were in a nursing home, based on his or her RUG category based on the Patient Review Instrument.  

2.  Supplemental Security Income (SSI)- Room and Board 

  • Congregate Care Level III Rate in schedules posted annually by NYS Office of Temporary & Disability Assistance (OTDA), which administers NYS Supplement to Federal SSI payment.  See charts--

16-INF-18 Attachment 1 – SSI and SSP Benefit Levels Chart Effective January 1, 2017

(For other years go to  https://otda.ny.gov/policy/directives/2017/#policy-archives and in INFORMATIONAL BULLETINS look for SSI   Benefit Levels Chart, usually posted toward the end of each year for the following year)

On 2017 chart, SSI level for a single person at Congregate Care Level III is $1429/mo.   If client's income is under this amount, and if her assets are within SSI limits ($2000 for single person plus burial arrangements, burial fund and some other exemptions)  s/he may be eligible for SSI to supplement her own income up to $1429.  The same is true for a couple to supplement their combined income up to $2,858 (couple rate 2017).  

A single person would receive a Personal Needs Allowance for sundry needs not covered by the facility -- in 2017, this is $194 per person (on same chart).  This is taken out of the SSI payment.

Examples of How Payment Works using SSI and Medicaid

EXAMPLE 1 - SSI and Medicaid:  Susan has $1300/month income from Social Security (gross.. before her Medicare Part B premium is withheld).  She is single.  The SSI program disregards $20 of her income, so that her countable income is $1280.    She is eligible for SSI for the difference between $1280 and $1429 (2016 income level) = $149.   She is eligible for a Personal Needs Allowance (PNA) of $194, which comes out of her income (see 16-INF-18 Attachment 1 – SSI and SSP Benefit Levels Chart Effective January 1, 2017  (2017)

 So she pays all of her income to the ALP facility, and  it gives her back $194 as her PNA .  (Or she keeps the SSI check of $147 and turns over her Social Security check to the ALP, which in turn gives her back the rest of her Personal Needs Allowance.)   Because she is on SSI, she automatically will receive Medicaid to pay the other part of the ALP bill, and she is automatically enrolled in the Medicare Savings Program so that Medicaid will pay her Part B premium. 

EXAMPLE II - Medicaid only, no SSI (private pay for residential services):  Ben has $1700/month Social Security (gross) assets of $13,000, and is single.   Since his assets are in excess of the $2000 SSI limit, he is not eligible for SSI.  However, he can still get Medicaid because his assets are below $14,850.  All of the rest of his income would go to the Assisted Living Program as his spend-down of $251:

($1700 - $20 disregard - $1429 =$251.   Under the Congregate Care Level III rules, he would not be entitled to a separate Personal Needs Allowance. 

Research and consumer information on Assisted Living generally in United States - see ProPublica.org  series of investigative articles


This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.

NYLAG

Attached files
file 2010_ ALP Model Contract 2010.doc (133 kb)

External links
http://www.health.ny.gov/health_care/medicaid/publications/docs/gis/05ma050.pdf

Also listed in
folder Medicaid -> Home Care

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