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Applying for Medicaid Personal Care or CDPAP Services in New York City - 2016 Changes
Where and how to apply for Medicaid personal care services and Consumer Directed Personal Assistance program (CDPAP) services has drastically changed with the implementation of mandatory Managed Long Term Care in New York State under a federal waiver that was approved September 4, 2012. The majority of individuals seeking Medicaid home care are now required to enroll in private managed care plans in order to receive those services. The process of applying for Medicaid and home care services is different depending upon what type of service, whether the applicant has Medicare, where the applicant lives, and new in July 2016, whether the individual has an "immediate need" for the personal care or CDPAP services. See this article for applying for personal care services outside of NYC.
The procedures have changed twice since 2012 - in Sept. 2012 and then again in July 2016: .
1. Most adult Dual Eligibles in NYC (age 21+ having Medicare and Medicaid) are required to enroll in Managed Long Term Care plans in order to receive Medicaid personal care or CDPAP. But they first apply to HRA for Medicaid.
Since September 2012, in NYC, and other parts of the state where MLTC became mandatory over the next three years, most adult dual eligibles (click here for exceptions) apply at HRA for Medicaid, but "the front door is closed" for obtaining home care through HRA. See NYC Medicaid Alert dated Sept. 6, 2012 and HCSP Central Medicaid Unit letter,
HRA--Home Care Services Program Central Medicaid Unit address effective Jan. 14, 2013
785 Atlantic Avenue, 7th Floor
Brooklyn, NY 11238
Do NOT apply at a CASA office or at another Medicaid office - when seeking home care, must apply at the address above. Some MLTC plans will file a Medicaid application for a prospective member..
2. People who are Exempt or Excluded from Managed Long Term Care - Who they are and Where they Apply for Medicaid and Home Care:
A. Those in the Following Categories are Exempt or Excluded from enrolling in MLTC:
1. Submit Medicaid application with "Supplement A" (DOH-4495A and all supporting documents and M11q to the following address If they already have Medicaid, include a copy of the notice of acceptance or the CIN number.
NYC HRA Home Care Services Program
109 East 16th Street, 5th Floor
New York, NY 10003
The M11q is the official HRA Form for applying for personal care. Until July 2016, an adult dual eligible applying for Medicaid who expects to enroll in n an MLTC plan would not have submitted this form to HRA. However, with the new procedures for people in Immediate Need of personal care or CDPAP services, the form is again required.
Q-Tips -Helping a doctor to complete the M-11q can be tricky, because the form uses many terms that are not universally understood by doctors. In addition, there are some details that are very important to assessing the need for home care, but which are not solicited on the form. To help you understand how to complete a successful M-11q, we have written a memo called Q-Tips. This version has been revised for the April 2010 M11q. The old version of the Q-Tips memo is also available in Spanish - we hope to update it for the 2010 M11q. Keep in mind that the M-11q is a medical document - non-doctors can assist in its completion, but in the end, a doctor must certify that the contents are true.
Home care advocates have found that the most effective M-11q forms are those that have detailed comments about the applicant's impairments and needs for assistance with activities of daily living. However, the M-11q form does not have much space for comments, and now the April 2010 form removes sections that formerly elicited some detailed comments by the physician. However, the M-11q form explicitly asks the physician to "attach an additional sheet(s) explaining the patient's condition in greater detail." We recommend that the M-11q form always be supplemented by this additional sheet of paper, with handwritten or typed comments spelling out the applicant's need for assistance with Activities of Daily Living in more detail. Here is an unofficial template.
30-Day Rule and "Stale" M-11q's
State regulation 505.14(b)(3) requires that the physician complete the physician's order (M11q) within 30 days of the medical examination of the client, and that the completed M11q be filed with the local district (CASA) within 30 days of the medical examination. The NYC HRA Home Care Services Program issued a Memo to all CASAs, dated May 26, 1995, that clarifies that as long as a signed M11q is submitted to the CASA within 30 days after the medical examination, it does not become "stale-dated" because it is in the CASA for more than 30 days without being acted upon. Moreover, this Memo clarifies that an M11q continues to be valid for one year after the medical examination.
30-Day Time Limit for HRA/CASA to Process M-11q
This time limit was agreed to in the 1978 settlement in Miller v. Bernstein (see par. 7). This is, obviously, not always complied with.
What are the regulations referred to in the Physician's Certification?
These are rules that have been in effect since at least the early 1990’s that provide sanctions and penalties for physicians who commit fraud, abuse, or who knew or had reason to know that services they prescribed were unnecessary, improper, or exceed the patient’s medical condition.
A federal audit found that some physicians who signed M11q forms had no record of ever seeing the individuals described in the M11q’s as patients. Signing an M11q for a patient who the doctor never saw would, of course, be a violation of the rules and subject to sanctions. However, the new certification goes further and warns doctors against prescribing services that are “unnecessary, improper or exceed the patient’s documented medical condition.” As long as a physician retains records of their treatment of the patient for the requisite six years, these records reflect the patient’s medical condition as described in the M11q, and the physician uses his or her reasonable professional judgment in recommending the amount of personal care services as medically necessary, s/he could not be subject to any sanctions.
Advocates can tell physicians that the warning was meant to weed out fraud – not good faith assessments of necessary services.
Gag Rule on Recommendation of Hours
Since 1992, state regulations have provided that in the physician’s order (M11q in NYC), the “medical professional must not recommend the number of hours of personal care services that the patient should be authorized to receive.” 18 NYCRR 505.14(b)(3)(i)(3). The rule was unsuccessfully challenged in court, so remains on the books.1 However, later developments in the personal care assessment process give authority for the treating physician to recommend, if not the number of hours, the “span of time” during which the need for personal care services arises.
1) Kuppersmith v. Perales, 688 N.Y.S.2d 96 (1999), affirming 668 N.Y.S.2d 381 (App. Div. 1st Dept. 1998).
2) This regulation was amended pursuant to the Stipulation in Mayer v. Wing, and is known as the “Mayer-Three” exception to Task-Based Assessment. See GIS Message 01 MA/044. Mayer v. Wing, 922 F. Supp. 902 (S.D.N.Y. 1996), modified in part, unpublished Orders (May 20 and 21, 1996); Stipulation & Order of Discontinuance (Nov. 1, 1997)(Agreement to amend this regulation is in 11/1/97 Stipulation).
3) Nurse’s assessment is required under 18 NYCRR 505.14(b)(3)(iii).
This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.