When a loved one requires long-term care in New York State, you will likely have plenty of questions about Medicaid coverage and eligibility. The Medicaid planning and application processes can be daunting, and many seniors have their applications rejected due to minor mistakes that could have been avoided. It is possible to increase the odds that your loved one will be accepted the first time around by understanding the ins and outs of eligibility requirements well in advance.
Below are commonly asked questions about Medicaid, which are accompanied by answers that are specific to New York’s statewide program. You will also find a list of waivers and long-term care programs that seniors with limited income and resources can utilize to get the financial and medical support they need.
What is the income limit for Medicaid eligibility in New York?
For an individual resident who is blind, disabled or over the age of 65 to qualify for the program, their monthly income must not exceed $825. The income limit for a married couple living in the community (both spouses applying) cannot exceed $1,209 per month. (Income limits for a couple where only one spouse is in a nursing home and the other spouse lives in the community are more complicated and will be addressed separately below.)
Unlike income-cap states, New York uses a “medically needy” approach to determine an applicant’s eligibility. If your income exceeds these limits, you may still be able to qualify if you incur significant medical expenses. This is known as the Medicaid Excess Income Program or the “Spenddown Program,” which functions like a deductible. Each month, the applicant must show that their applicable medical expenses exceed or are equal to their excess income in order to receive coverage of additional medical services for the remainder of each month.
Is there a limit on assets that I can keep and still be eligible for Medicaid?
Whether your loved one is living in a nursing home, an assisted living facility, or intends to live in the community for as long as possible by receiving in-home care, the asset limit for is as follows:
- An individual applying will need to have $14,850 or less in available resources.
- A married couple's combined resources (both applying) cannot exceed $21,750.
Any assets in excess of this amount will need to be “spent down” on care and needs in order to achieve eligibility. Planning and “spend down” can get tricky and the rules of the game are constantly changing, so one needs to be well informed or consult with an experienced elder law attorney or planning specialist on what is advisable and what is not.
What assets count toward Medicaid eligibility?
Any assets that you can access and turn into ready cash count towards the limits listed above, including:
- Money in savings and checking accounts
- Mutual funds
- Life insurance policies with a face value in excess of $1,500
- Property other than your primary residence
- Motor vehicles if you have more than one
- Retirement accounts
Excess assets will need to be converted to cash and put toward the applicant’s medical bills or spent down before they can qualify.
What assets do not count?
Many seniors are worried about what might happen to their home once they need assistance paying for care. An applicant’s home is exempt as long as its equity value (fair market value minus any debts secured by the residence) does not exceed $828,000. If the home is jointly held by the applicant and someone else, such as a spouse, then Medicaid uses the applicant’s equity interest to determine their eligibility. For two joint owners, the equity interest is one half of the equity value. In accordance with the calculation methods above regarding ownership, if the home’s equity value or the applicant’s equity interest in the home exceeds $828,000, then the program will not pay for long-term care services. One exception to this is if a community spouse or a child who is under 21, disabled, or blind lives in the residence.
One vehicle is exempt from asset limits as well. Personal possessions are not counted either, so no one will go through a home looking at antiques or other personal items to determine whether or not they can be sold to fund a person's care.
Applicants can also plan for their funeral and burial expenses with an irrevocable pre-need funeral agreement worth up to $1,500 for single individuals and up to $3,000 for a couple. Furthermore, applicants are able to set money aside in a special needs trust (also known as a supplemental needs trust) for their disabled children that will not count toward their existing assets and potentially disqualify them from needs-based public and health benefits like Supplemental Security Income (SSI) and Medicaid.
Can the children keep any assets?
When the time comes to spend down assets in order to qualify for these services, many seniors wish to pass this money on to their children and heirs. Unfortunately, the program will conduct a five-year look-back at financial statements to see if any large asset transfers have been made to children or other family members and friends. These gifts can disqualify them from the program and they will incur a penalty period during which they will not receive coverage or services. There are only a few exceptions. A minor, blind or disabled child may be able to keep the primary residence and some assets if planned for properly. An adult child who moved into the primary residence to care for an aging parent and lived there for at least two years may also be able to keep the residence under some circumstances.
What purchases can be made with assets to help with eligibility?
A senior’s assets can be used for permissible expenses until they reach the asset requirements. These include payments of debts, personal care items, including clothing and medical supplies, home repairs, home modifications, durable medical equipment prescribed by a doctor, and funeral and burial expenses. Large gifts, however, will count against their eligibility.
One member of the couple is in a nursing home and the other lives in the community. How much income can each of them keep?
An individual in a nursing home in New York can only keep $50 of their income each month as a personal needs allowance, while a resident in an assisted living facility may keep $193. The rest of their Net Available Income (NAMI) must be paid to the nursing home for their room and board.
The community spouse is entitled to $2,980.50 in income each month, which is also known as the minimum monthly maintenance needs allowance (MMMNA). If their income is less than this amount, part of the institutionalized spouse’s income will be directed to the community spouse to make up the difference. On the other hand, if the community spouse’s income exceeds the MMMNA, they are required to contribute 25 percent of the excess amount to their spouse's nursing home care. The community spouse may also be able to receive more than the minimum amount from the institutionalized spouse’s income if they go to family court and sue for an order of support or request a fair hearing.
What are the asset rules for a couple when one spouse lives in the community and the other is in a nursing home?
While an individual in a nursing home is only allowed to keep $50 in income, they can still retain $14,580 in non-exempt assets. However, New York allows community spouses to keep significantly more assets in order to prevent spousal impoverishment. This allows them to continue living with a reasonable quality of life while still permitting the ill spouse to receive the care they need.
According to 2016 New York State Income and Resource Standards and Federal Poverty Levels, “the community spouse is permitted to retain resources in an amount equal to the greater of the following: $74,820 or the amount of the spousal share up to $119,220. The spousal share is the amount equal to one-half of the total value of the countable resources of the couple as of the beginning of the most recent continuous period of institutionalization of the institutionalized spouse.”
What waivers and programs exist in New York that specifically benefit seniors and their caregivers?
The Managed Long-Term Care Waiver provides services for individuals who need special care at home in order to avoid moving into a nursing home. This program allows individuals who need long-term care to stay at home longer while still receiving medically necessary services. Proof that the individual would need to move into a nursing home without this type of home-based care is necessary in order to qualify.
The Assisted Living Program (ALP) helps individuals who aren’t quite in need of nursing home care yet, but who do need specialized medical care. Assisted living facilities are for those who need less intensive and medically-directed care, but more assistance than can be provided at home. In order to qualify for this program, individuals must prove that this care is necessary.
The Consumer-Directed Personal Assistance Program (CDPAP) provides home health aides, nurses, and other in-home services to individuals who need this care in order to remain at home. It requires a visit to the doctor, who must prescribe these services and certify that the individual requires this high level of care. Recipients of this program are able to choose their own caregivers, raising the incentive to utilize the program. With only a few exceptions, seniors and disabled individuals who are eligible for this waiver can choose a friend or family member to provide and receive payment for these services through a written agreement or contract. However, spouses and legal guardians are unable to receive payment for their care. This consumer direction method of managing services is also commonly referred to as “cash and counseling.”
The New York Expanded In-Home Services for the Elderly Program (EISEP) covers non-medical home care needs. This might include assistance with activities of daily living (ADLs) like cleaning, cooking, or basic maintenance that the individual is no longer able to complete. This program requires clients to help pay for the cost of the service based on their income. These contributions are based on a cost-sharing sliding scale.
The New York RESTORE (Residential Emergency Services to Offer Repairs to the Elderly) Program helps cover the cost of emergency repairs which homeowners cannot afford to pay for themselves in a timely manner. Eligible senior homeowners must be 60 years of age or older and reside in the home that requires repair. Projects commonly covered by RESTORE include roof repairs, HVAC system repair or replacement, and restoration of hazardous indoor/outdoor stairways.
The New York Elderly Pharmaceutical Insurance Coverage (EPIC) Program helps supplement insurance policies to cover out-of-pocket medication costs. It is designed to help pay for the portion of prescriptions that Medicaid does not cover, preventing seniors from forgoing needed medications due to financial strain.
The Personal Care Services (PCS) Program helps provide help with personal care tasks (activities of daily living) in an individual’s home. This may include taking care of basic grooming tasks, helping with bathing and a variety of other tasks that the individual can no longer complete on their own. Eligibility for this program is based on the need for these services in order for the individual to maintain their overall quality of life.
The key to understanding Medicaid eligibility is to be properly educated ahead of time. Do not wait until the last minute to start learning about this program in New York! There is help out there that can guide you through planning, application and the receipt of services.
Benny Lamm is a communication specialist and blogger at Senior Planning Services, an industry leader in helping seniors and their families achieve Medicaid-sponsored long-term care. He enjoys playing the guitar, spending time with family and social networking.