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.
IN THIS ARTICLE:
1. DIFFERENCE BETWEEN ASSISTED LIVING PROGRAM (ALP) and OTHER ASSISTED LIVING RESIDENCES (ALR) or FACILITIES (ALF)
Only official licensed Assisted Living Programs (ALPs) accept Medicaid and SSI to pay the fees. Most Assisted Living Facilities (ALF), 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 or consumer-directed 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
Special Needs Assisted Living Voucher Demonstration Program-- The 2018-19 NYS budget established a new program to subsidize the cost of non-Medicaid assisted living for those individuals living with Alzheimer’s disease and dementia who are not eligible for Medicaid. The program will authorize up to 200 vouchers to individuals through an application process and pay for up to seventy-five percent of the average private pay rate in the respective region. This program is rintended to allow ALF residents who run out of money to pay the private fees to remain in the facilities. As of June 23, 2021, the SNALR Voucher Program has instituted a waitlist for new applicants to the program.
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
The complaint in a April 2018 federal lawsuit challenging disability discrimination in NYS assisted living reviews the legislative and regulatory framework of assisted living in NYS. The lawsuit was filed against the NYS Department of Health and two Assisted Living Programs in NYC, challenging discrimination based on disability and violation of the federal Fair Housing Act because state regulations and the individual facilities prohibit admission to people who rely on wheelchairs. See link to New York Times Article Wheelchairs Prohibited in the Last Place You’d Expect, April 20, 2018 and download complaint here. The plaintiffs are the Fair Housing justice Center and two individual plaintiffs and are represented by Mobilization for Justice, Inc. and AARP Foundation Litigation. On Sept. 24, 2018, the federal court partially granted a preliminary injunction, which requires the defendant to reinstate the tenancy of the named plaintiff in her apartment, so that she could return home from the nursing home she had been trying to leave, with anticipated enrollment into a Managed Long Term Care plan to provide her with services. 2018 WL 4565152.
The Assisted Living Program is slated to be transitioned to become a benefit within the Managed Long Term Care and mainstream Medicaid managed care program. The transition was due to begin on July 1, 2017; but was delayed until Oct. 1, 2018 for New York City and Jan. 1, 2019 for the rest of the state. As of June 2021 the implementation date appears to again be delayed,
ALP ADMINISTRATIVE DIRECTIVES:
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.
2018-19 State budget --
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.
While private payment is possible, for people who meet the financial and other eligibility criteria, payment is made through a combination of:
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.
(For other years go to https://otda.ny.gov/policy/directives/2019/#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 2021 chart, SSI level for a single person at Congregate Care Level III is $1488/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 $1488. However, all of that except a Personal Needs Allowance (PNA) must be paid to the facility for room and board. The PNA is for sundry needs not covered by the facility - cell phone, clothing, metrocard, etc. -- in 2021, the Personal Needs Allowance is $210 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 $1488 (2021 income level) = $208. She is eligible for a Personal Needs Allowance (PNA) of $210, which comes out of her income (see 20-INF-12 Attachment 1 - 2021 SSI and SSP Maximum Monthly Benefit Levels Chart)
So she pays all of her income to the ALP facility, and it gives her back $210 as her PNA . (Or she keeps the SSI check of $208 and turns over her Social Security check to the ALP, which in turn gives her $2 - the balance 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 $15,900 (2021). All of the rest of his income would go to the Assisted Living Program as his spend-down of $192 (2021):
($1700 - $20 disregard - $1488 =192). He can enroll in a pooled trust to deposit the $192 and he will have no spend-down.
Research and consumer information on Assisted Living generally in United States -
This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.