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Medicaid Home-and-Community-Based Waiver Programs in New York State
Medicaid home and community-based services [HCBS] are available through waiver programs to groups of individuals who would be eligible for Medicaid if institutionalized and, but for the services, would be institutionalized in a hospital or nursing facility. Under section 1915(c) of the Social...
Medicaid Certified Home Health Agency (CHHA) Services
A Certified Home Health Agency (CHHA) provides what is commonly known as “visiting nurse” services, as well as physical or occupational or speech therapy (PT/OT) in the home, "home health aide" (HHA) services, and medical supplies. The nursing visits are "part-time or intermittent " and NOT...
HIPAA Forms and Health Information Access and Privacy - Overview
You have the right to privacy concerning information about your health, medical care, and how your care is paid for. This right comes from a federal law called HIPAA (Health Insurance Portability and Accountability Act). Although HIPAA regulates many other areas, the main impact it has on most...
Legal Authorities Relating to Supplemental Needs Trusts
There is a confusing patchwork of Federal and State laws and regulatory guidance governing the use of Supplemental Needs Trusts in the Medicaid context. This article is intended to collect some of these authorities in one place. One of the prerequisites for using a Supplemental Needs Trust is...
NYS Directives on Medicaid changes under the Affordable Care Act
The New York State Department of Health (DOH) has issued additional directives outlining the new procedures for Medicaid applications and renewals under the Affordable Care Act, effective in 2014. For newest directives scroll to the bottom of this page. 1. 13 ADM-04 - Medicaid Application...
"Qualified Medicare Beneficiaries" (QMB) - Protections against "Balance Billing"
THE PROBLEM: Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB). His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under...
Medicaid Disability Determinations - NYS Forms & Procedures (with updated forms July 2012)
The Medicaid program has long had a procedure for determining disability for individuals who have not yet been determined disabled by the Social Security Administration.[1] There are different reasons for determining disability. The procedure is primarily used for Medicaid recipients between...
Step-by-step guide to enrolling in a pooled income trust for Medicaid spend-down
This article is intended as a condensed road-map for using a pooled income trust to eliminate the Medicaid spend-down. This article contemplates that the individual is applying for Medicaid in order to obtain home care services. The sequence of events will be different if that is not the case. I...
Income and Resource Limits for New York State Public Health Insurance Programs
Here is the 2019 HRA Income and Resource Levels chart. This short summary chart shows that income limits have increased for the new "MAGI" category created by the Affordable Care Act, but not for the "Non-MAGI" population - the Disabled, Aged 65+ and Blind (DAB). Non-MAGI ...
2015 NYS Law Gives Protection from Surprise Bills and Emergency Services
A new New York State law went into effect March 31, 2015 that protects consumers from "surprise bills" when services are performed by a non-participating (out-of-network) doctor at a participating hospital or ambulatory surgical center in your HMO or insurer's network or when a participating...
Medicaid Alerts & Other Protocols published by the NYC HRA Medical Insurance and Community Services Administration (MICSA)
HRA MICSA Alerts are periodic announcements of policy, staff and office changes published by the Medical Insurance and Community Services Administration (MICSA). MICSA is the part of New York City’s Human Resource Administration (HRA) that administers HRA’s medically- related programs such as...
Managed Long Term Care
State Complaint Number for MLTC Problems - 1-866-712-7197 e-mail mltctac@health.ny.gov and put "COMPLAINT" in subject line For enrollment complaints - call NY Medicaid Choice - 1-855-886-0570 (Advocates line) 1-888-401-6582 (Consumers line) Managed Long Term Care (MLTC)...
Spousal Impoverishment Protections for Married Couples where One Spouse is in a Managed Long Term Care Plan - Pooled Trusts Allowed as an Option
A. What are Spousal Impoverishment Rules? Since 1998, a spouse of a nursing home resident on Medicaid is allowed to keep a reasonable level of income and resources to live on, while still permitting Medicaid payment for the nursing home resident's care. Congress enacted the "spousal...
Medigap (Medicare Supplemental) Policies and Rates in New York State - with Rate Tables for the Current Year
Medigap (aka Medicare supplemental insurance) policies are sold by private health insurance companies to cover some of the "gaps" in expenses not covered under original Medicare. 2019 NOTE: AARP Medigap Plans - UnitedHealth has applied to the NYS DFS for approval of rate increases, which would...
Long Term Care Insurance
Long term care insurance is a product which, if certain conditions are met, will pay for all or a portion of, nursing home and/or home care expenses. Such policies have been marketed to individuals who do not wish to have their assets depleted should they need long term care. While such policies...
Medicare Savings Programs (MSP) in New York
Funded by the State Medicaid program, Medicare Savings Programs (MSPs) help eligible individuals meet some or all of their cost-sharing obligations under Medicare. See N.Y. Soc. Serv. L. § 367-a(3)(a), (b), and (d). There are three separate MSP programs, the Qualified Medicare Beneficiary (QMB)...
List of Pooled SNTs in New York State
This is an unofficial list of non-profit organizations in New York State that offer pooled Supplemental Needs Trusts (or similar services) to people with disabilities. We do not claim that this is an exhaustive list; there may be other pooled trusts in the state of which we are unaware. In...
KNOW YOUR RIGHTS: Fact Sheet Explaining Basic Rules on NYS Financial Medicaid Eligibility for People who are Disabled, Aged 65+, or Blind
This Fact Sheet (updated March 2019) is intended for New Yorkers who are age 65+ or who have disabilities, or their family members and caregivers. It explains the basic financial rules on eligibility for Medicaid in the community for this category of people, and explains how to apply for Medicaid...
Nursing Home Medicaid Coverage - Basic Financial Eligibility Rules about Income, Resources, and Spousal Protections
Medicaid rules are different for people living in the "community" than people living in institutions. For this article, the word "institution" means nursing home care. If you live in your home, someone else's home, or an Assisted Living Program, you are considered to live in the "community." ...
KNOW YOUR RIGHTS: Managed Long Term Care and FIDA - Fact Sheets, Live and Recorded Webinars
Fact Sheets on Managed Long Term Care and FIDA. FACT SHEET 1: Basics on Managed Long Term Care FACT SHEET 2: Grievance and Appeal Rights in Managed Long Term Care - new Requirement to Request Plan Appeal Before a Fair Hearing FACT SHEET 3: FIDA: New Program for Dual Eligibles...
New Permanent Nursing Home Residents in NYS Required to Enroll in Medicaid Managed Care Plans or MLTC Plans - Effective since October 2015 Statewide
July 2018 Update - All of the policies and procedures described in this article will be changing soon, as the result of the NYS Budget enacted in April 2018. This budget reverses the MLTC expansion to include nursing home care that is described in this article. Once implemented, adults with...
Medicaid for Immigrants who are Not Permanent Residents (Do Not have "Green Cards")-- PRUCOL and Temporary Non-Immigrant Eligibility
September 2018 ALERT - On Sept. 22, 2018, the Trump Administration proposed changes on the standards for deciding whether an immigrant who receives Medicaid or other government benefits is considered a "public charge" which can result in denial of Lawful Permanent Resident status (green card),...
Medicaid & MSP: Must apply for Social Security and Enroll in Medicare
Medicaid applicants and recipients can be required to pursue potentially available income, including Social Security, as a condition of receiving Medicaid, and also to apply for Medicare. (42 CFR 435.608; 18 NYCRR sec. 360-2.3 (c)(1); Medical Assistance Resource Guide [MARG] pp. 488-489.) ...
Pathways to Extra Help - the Part D low income subsidy and how it can help your clients
There is a special program called the Low Income Subsidy (LIS) which helps with Medicare Part D cost sharing. LIS is also known as "Extra Help." The Social Security Administration administers LIS you don't apply through your Part D plan. See Medicare Rights Center chart on 2019 Extra Help...
When an MLTC Plan Closes - What are the Members' Rights?
Now that enrollment in Managed Long Term Care (MLTC) plans has been mandatory for 5 years for most adult "dual eligibles" (people with Medicaid and Medicare) who need Medicaid home care, some of the original MLTC plans have either closed altogether, or have reduced their service area, no longer...


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