New York State has a range of Medicaid home care service programs, each oriented toward slightly different needs and sometimes to different populations. These programs are listed below, with links to detailed information posted on this site.
Beginning in September 2012, for ADULTS age 21+ who have Medicare (known as "dual eligibles"), some of the services listed below can only be accessed by enrolling in a Managed Long Term Care [MLTC] plan. The requirement to enroll in an MLTC plan if one needs long-term home care is being rolled out statewide on a gradual basis - first in New York City in September 2012, then in Long Island and Westchester in January 2013 and Orange and Rockland counties in approximately July 2013.
As of June 2013, most people who do not have Medicare, and who are enrolled in a mainstream Medicaid managed care plan, must access the following home care services through their managed care plan. This includes personal care, Consumer-directed personal assistance, certified home health care, and private duty nursing services.
The different home care services programs are as follows. Click on the hyperlinks for more information.
Medicaid Personal Care services (a/k/a Home Attendant services in NYC)
Certified Home Health Agency (CHHA) services
Consumer Directed Personal Assistance Services
Private Duty Nursing or LPN services -
DOH 08-INF–5 (Aug. 18, 2008) - Guide to Accessing Medicaid Private Duty Nursing Services in the Community (issued before these services were brought into the benefit package of Managed Long Term Care and mainstream Medicaid Managed Care -- establishes procedures for applying for nursing services for those not in MLTC or managed care, requires decisions to be made within 21 days of a fully documented application. It explains how to obtain a list of Medicaid private duty nurses in the local area by calling the Medicaid helpline at 1-800-541-2831 and online at www.homecare.nyhealth.gov. Establishes statewide procedures for obtaining Medicaid private duty nursing services if there is difficulty finding a provider, including requesting local DSS for a DOH case-specific enhanced payment rate. The enhanced rate is applicable in all DSS districts in the State pursuant to the Settlement in Leon v. Danes, et.al., (CV 07-1674 E.D.N.Y, June 12, 2008).
REGULATIONS: 18 NYCRR §§ 505.8; 505.13
MLTC Policy 13.07: Private Duty Nursing Summary - applies to MLTC plans
Sample Fair Hearing decision reversing denial of private duty nursing and directing 24-hour split-shift nursing care (11/10.20) - FH No. 8193302Y
Waiver programs - Lombardi, Traumatic Brain Injury (TBI), Nursing Home Transition & Diversion Waiver (NHTDW), Care at Home, etc.
Managed Long Term Care programs
Hospice care - as of June 2013, people enrolled in MLTC plans may obtain hospice services from a hospice provider outside the MLTC plan, and do not have to disenroll from the MLTC plan. The MLTC plan continues to provide all other long-term care services. See State DOH MLTC Policy 13.18; MLTC Policy 13.18(a): Update MLTC Guidance on Hospice Coverage, MLTC Policy 13.18(b): MLTC Guidance on Hospice Coverage Update; Hospice and MLTC FAQ
This listing gives the statutory, regulatory, and administrative cites for each of the home care programs, along with leading caselaw.
The United Hospital Fund published, in May 2009, a comprehensive report on Medicaid long-term care programs in New York, which serve 247,000 Medicaid beneficiaries each month and account for roughly one quarter of all Medicaid spending. An Overview of Medicaid Long-Term Care Programs in New York. The report provides an excellent portrait of each program's demographics, usage, and function, using September 2007 as a snapshot.
This chart summarizes some of the key differences between the programs.
ONLINE LIST OF CHHAs, Licensed Home Care Services Agencies (LHCSA) and hospices -- searchable by county and region - https://profiles.health.ny.gov/home_care
- NOTE that licensed home care services agencies (LHCSA) may not bill Medicaid or Medicare directly. You may hire aides from a LHCSA privately or through some private insurance. Also, if you receive services from a CHHA, waiver program, the aides may be employed by a LHCSA, not by the CHHA or waiver program that is managing the over-all care plan and that is billing Medicaid. The CHHA or waiver program contracts with the LHCSA to provide the aid services as part of the plan of care, but the overall care is managed by the CHHA or waiver program.
FAIR HEARINGS -- Hearings are often required to obtain an increase in hours of personal care/home attendant services or Managed Long Term Care services, to contest denials of applications based on the alleged need for a "higher level of care," etc.
- Since November 2010, the state Office of Temporary & Disability Assistance, which runs fair hearings, has posted all decisions in redacted format in a searchable online database at http://otda.ny.gov/hearings/search/. These are heavily redacted.
- Some earlier decisions, as well as pertinent recent ones, are posted by advocates on the Online Resource Center on the Western New York Law Center website. For access, register and "log in" and select "Fair Hearings" tab to access the database. The database is partly searchable -- by keywords used by advocates when the post decisions, but not by the entire decision.
- This Digest of Medicaid Fair Hearing Home Care Decisions is another way of identifying hearing decisions on the various types of Medicaid home care listed above, which may be helpful to show a roadmap for preparing for a hearing, or to cite as precedent at a fair hearing.
This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.