Changes to Community Medicaid

In our last issue we reviewed certain changes to community based Medicaid eligibility (home care) which had been incorporated in the 2020 budget but had not yet been implemented because of the pandemic emergency. We noted that, previously, eligibility required an applicant to be incapable of performing two of six activities of daily living: eating, bathing, dressing, transferring, toileting, and ambulating whereas, under the new rules, unless the applicant suffers from dementia, eligibility is based on the inability to perform three of the six activities of daily living.


The 2020 budget also addressed changes to the way in which enrollment in a Managed Long Term Care Plan (MLTCP) will occur. Effective May 16, 2022, after new applicants have been approved financially, they will no longer go through the conflict free assessment process. Instead, the Department of Social Services will refer these eligible applicants to the New York Independent Assessor [“NYIA”] which will schedule two assessments to determine eligibility in an MLTCP.


The first assessment: the Community Health Assessment [“CHA”] is conducted by a NYIA nurse, in the applicant’s home, to determine whether the applicant meets the appropriate need for community long term services. This assessment may be done in person or via telehealth and can be scheduled any weekday: Monday through Friday 8:30am- 5pm or Saturday and Sunday 10am-6pm.


The second assessment: the Clinical Appointment [“CA”] is performed by an Independent Practitioner Panel (IPP) of medical doctors, osteopathists, nurse practitioners and physician assistants who will review the CHA and perform a thorough medical exam of the applicant, in person or via telehealth, to determine if the applicant is medically stable enough to remain in the community. The CA assessor will make personal care service recommendations and complete the physician order form but will not award services or determine hours of care.


After both assessments, NYIA will inform the applicant of the results in writing and, if approved, refer the applicant to an MLTCP which will develop a plan of care and award hours using the CHA assessment and the physician order form. If the MLTCP concludes that the applicant requires 12 or more hours of care per day, the applicant will go through a high need review by NYIA’s independent review panel which will determine if the proposed plan is reasonable and appropriate for the applicant to remain safely at home. The MLTCP will make the final decision and issue the notice.


Under this new system, assessments are done by medical professionals who are not familiar with the applicant. You may wonder whether your primary care physician can provide input in this process. We recommend the following:


• Have your physician write a letter of medical necessity to the CHA and CA assessor;


• Share your medical records: NYIA allows you to share your medical records with the assessors by going to en/for-authorized-representatives;


• Prepare for the assessments in advance and present to both the CHA and CA assessors a list of all diagnoses and medications;


• Retain an advocate who can assist you in preparing for the assesments and will be present throughout the process to ensure that your specific needs are properly catalogued.


Some good news: under the new system, reassessment occurs once annually not every six months.