Home Care and Community-Based Medicaid FAQ

Home and personal care services are covered by Medicare Home Care and available to eligible seniors and disabled individuals in New York. Many receive these services through a Managed Long Term Care Plan (MLTC) that provides services from licensed Home Care Services agencies or contracted service providers.

Others in NY who prefer to select their own providers, which may include paid family caregivers, can receive Medicaid Home Care benefits through the Consumer Directed Personal Assistance Program.

Some who require skilled, short-term home care services and home health aides will benefit from Certified Home Health Agencies.

In New York State, Community Medicaid provides seniors with standard health insurance that covers doctor and hospital visits, laboratory tests, x-rays, and prescribed medication. With long-term care services, the elderly can remain in their communities and receive home and personal care, live in assisted living facilities, and/or benefit from adult day care.

Serving as an alternative to Nursing Home/Institutional Medicaid, this program allows eligible seniors to stay home while benefiting from covered care services. Assistance can include “activities of daily living” or ADLs that include bathing, dressing, eating, toileting, and transferring.

To qualify for Community Medicaid in NY, you must first be over the age of 65 or be an individual with disabilities. An established need must be determined for ADLs (activities of daily living) services that can include activities such as bathing, eating, bed mobility, personal hygiene, and some personal care tasks, among others. In order to determine this eligibility (established need), an evaluation is performed to verify and/or approve that long-term care is required.

In addition, recipients of Community Medicaid must meet financial requirements that include income and assets. If there is a primary residence, it may be considered exempt if the beneficiary, spouse, minor or disabled child is residing in the home.
For help in becoming eligible for NY Community Medicaid, contact us today.

Medicaid versus Medicare

Medicaid assists seniors and disabled persons by providing health coverage based on certain criteria and qualifications including low-income requirements. The Medicaid program is also available to qualifying children, adults, and pregnant women who cannot afford to pay for health care services. In all cases, those seeking eligibility must meet requirements established by state and federal law.

A Benefit ID Card will be issued once you become eligible for Medicaid benefits, which will be needed to obtain medical care and services.

Medicaid covers a wide array of medical care based on the age of the beneficiary, financial and household situation, living arrangement, and other requirements. The following services may or may not be covered by Medicaid or your “managed care plan” depending on your particular circumstances and may or may not require small co-pays. Services must first be approved and limitations may apply to certain services.

Long-term care
At-home care (via home health agencies) and personal care
Nursing home care
Doctor and hospital visits
Health clinic services
Lab and x-rays
Hospitals (outpatient and inpatient)
Mental health care services
Medical equipment/appliances, supplies, medicine
Health and dental care treatment
Eyecare/vision and glasses
Transportation to medical visits
Emergency transportation (ambulance) to hospital
Certain Medicare and insurance premiums
Other healthcare services

Medicaid
Medicaid is a jointly funded state and federal program that provides eligible seniors with coverage for long-term home care. The Medicaid home care program covers long-term and personal care costs including community and home care as well as doctor and hospital visits. Unlike Medicare, however, health insurance and prescription costs are not covered by Medicaid.

Medicaid also provides health coverage for low-income individuals including the elderly and disabled persons, and others (low-income adults, pregnant individuals, children) deemed eligible. The program is run by the states while adhering to federal requirements. Since state benefits vary, contact your state for information.

For more information on mandatory and optional Medicaid benefits, visit this Medicaid benefits page.

Medicare

Medicare, on the other hand, is a federal health insurance program for those 65 years of age and older and individuals under 65 yrs. old with eligible disabilities. In addition, people at any age with permanent kidney failure requiring treatment or those with Amyotrophic Lateral Sclerosis/ALS may receive benefits from Medicare.

Unlike Medicaid, Medicare (Parts A and B) does not provide coverage for long-term home care services that are considered “personal” (not medical). Personal care includes activities that fall into daily living needs such as bathing, dressing, toileting, eating, etc. Traditional Medicare, however, will provide some personal or “custodial” coverage when such care is supporting home care that is addressing a skilled or medical need.

Medicare is your primary coverage, which means claims are first paid by this program before Medicaid kicks in. The Medicaid program will then pay for covered benefits that Medicare does not cover.

Medicaid Eligibility

Medicaid eligibility is based on income and household size and differs from one state to another. Free and low-cost healthcare coverage is available to elderly individuals, as well as pregnant women, families, and children within certain income limits, and people with disabilities. Other adults (over 18 yrs.) whose income levels fall within certain required limits can also receive coverage in some states.
If you are an adult over the age of 18, require skilled nursing care or skilled level care, and qualify for Community Medicaid, you may qualify for home care coverage. This allows you to stay in your home while receiving the same level of care as a nursing home. Note: You may not participate in other Home and Community-Based Services (HCBS) waivers to be eligible.

Because eligibility varies from state to state, you will want to contact your state Medicaid agency for details on what the requirements are to qualify.

If you are a New York state resident, you can find a list of qualifications here. If you are looking for long-term home and community-based benefits, you may qualify if you are over 65 years old and meet certain state income requirements. Other qualifiers include being legally blind or people with disabilities at any age.

The Medicaid benefits you may be eligible for depends on your age, need, health condition(s), and household situation. To learn what government benefits may be available to you, check your eligibility by answering a series of questions at the Benefit Finder.

Each state has set income limits required to receive benefits. If your monthly income, for example, exceeds your state’s limits, you may not qualify for benefits. However, there are strategies like joining a Pooled Trust (in New York) to help you qualify for Medicaid.

Spend Down and Pooled Trust Options

There are ways to still meet eligibility requirements even if your income exceeds the required limitations. One way is to “spend down” your excess income by paying medical bills, which then allows the Medicaid coverage to kick in. Other ways may include exempt health insurance premiums paid, deducted earned income, and joining a pooled trust to shelter your excess income.

Income eligibility limits can be frustrating for seniors seeking Medicaid benefits. Spending down your excess income is one way to qualify. But you can avoid having to spend down this income by restructuring your income and assets. Doing so allows you to continue to pay your living expenses and care for those at home.

Another way to avoid spending down your excess income in New York is by joining the KTS Pooled Income Trust.

Seniors who want to remain in their homes and benefit from home health care have found that joining a pooled income trust can help them qualify for Community Medicaid while sheltering their excess monthly income.

By joining the Pooled Income Trust, those seeking long term home care can eliminate the need to spend down their excess income while continuing to pay for reoccurring living expenses like phone bills, utilities, etc.

Although the name “pooled trust” implies a collection of funds, funds with the trust are placed in a separate account, which are then be used to pay a member’s bills on their behalf. The pooled income trust is permitted by law and must adhere to rigid rules and requirements.

Let KTS Pooled Trust help you (or your loved one) remain at home while receiving the health and personal care you need. Contact us for a free consultation.

Applying for Medicaid

Applying for Medicaid

If you are applying for New York Medicaid, there are a few ways to apply:

You can apply directly online at NY State Medicaid agency marketplace or call the Marketplace Customer Service Center call (855) 355-5777 (TTY: 1-800-662-1220).
Contact an MCO (Managed Care Organization).

Contact your Local Dept of Social Services Office.

Contact (800) 541-2831, Medicaid Helpline.

If you’re in New York and need help with the application and eligibility process, contact KTS Pooled Income Trust for personalized assistance and we’d be happy to walk you through the steps.
If you are not in NY state, you can start the process by applying online at the Health Insurance Marketplace. In addition, you may apply by contacting your state’s Medicaid agency.

Applying for Medicaid is the first step towards receiving benefits. Once the application is received, the state and federal agencies will determine eligibility by reviewing your income and assets. This means you will need to collect documentation to prove your income, asset statements, and benefits statements (e.g., SSI).

The time required to complete the Medicaid application process varies from applicant to applicant. It can take weeks or months for completion depending on the applicant’s situation and documentation.

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