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New York State Department Of Health Issues New Administrative Directive Related To Expedited New York Medicaid Eligibility For Personal Care Services And Consumer Directed Personal Assistance Services

On July 1, 2016 The New York State Department of Health issued Administrative Directive 16 OHIP / ADM-02 setting forth the requirements and procedures for expedited Medicaid eligibility determinations for New York Medicaid applicants/recipients who have an “immediate need” for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS).

This Administrative Directive is significant for those who are in immediate need of PCS or CDPAS because they do not have the means to pay for such care and do not have family members or other informal caregivers that are able to provide such needed care. The PCS program provides needed assistance with personal hygiene, dressing, feeding and incidental household services. The CDPAS program enables Medicaid recipients, who are eligible for home care services, to have greater flexibility and freedom of choice in obtaining needed services. Under the CDPAS program, the Medicaid recipient or designated representative manages the plan of care and may hire the individuals to provide the services authorized in the approved plan of care.

New York State Social Services Law requires that the final Medicaid eligibility determination for individuals with an immediate need for PCS or SDPAS be made within seven (7) days of receiving the complete Medicaid application. The above mentioned Administrative Directive provides for a new Notice and Attestation form that must be completed by the applicant in immediate need of such services along with the required procedures to be followed by the local New York Medicaid offices. To receive an expedited determination, applicants must now provide the Local Department of Social Services (LDSS) with a physician’s order for PCS or CDPAS and a signed attestation by the applicant attesting that:

(1) they have an immediate need for PCS or CDPAS;
(2) they have no voluntary informal caregivers available, able and willing to provide or continue to provide needed assistance;
(3) they have no home care services agency providing needed assistance;
(4) adaptive or specialized equipment or supplies including but not limited to bedside commodes, urinals, walkers or wheelchairs, are not in use to meet, or cannot meet, their need for assistance; and
(5) third party insurance or Medicare benefits are not available to pay for the needed assistance.

This attestation is available via NYS Dept. of Health Form OHIP-0103.

As soon as possible, but no later than four (4) calendar days after receipt of a Medicaid application (or request for an increase in Medicaid coverage to include community-based long-term care), together with the physician’s order and signed attestation of immediate need, the LDSS is required to determine whether the Medicaid applicant has submitted the complete Medicaid application. If the applicant has not submitted a complete Medicaid application, the LDSS must notify the applicant of the additional documentation needed, and provide the date by which the applicant must provide the documentation.

Once a complete Medicaid application has been received, the LDSS must determine Medicaid eligibility within seven (7) calendar days and send notification to the applicant. The seven (7) day period starts the day after all documentation is received.

As soon as possible, but not later than twelve (12) calendar days after receipt of the complete Medicaid application, the LDSS must obtain or complete a social assessment and nursing assessment and determine whether the Medicaid applicant, if determined eligible for Medicaid, would be eligible for PCS or CDPAS and, if so, the amount and duration of services that would be authorized. To expedite the process, the LDSS must not wait until the results of the Medicaid eligibility determination before assessing the applicant’s eligibility for PCS or CDPAS.

Under the expedited procedure applicants in the SSI-related category of Medicaid assistance (age 65 and older, certified blind and/or certified disabled) with an immediate need for PCS or CDPAS may attest to the current value of any real property, equity value of the homestead, and current value of any bank accounts. (The documentation requirements for all other assets remain the same.) However, if the LDSS has information that is inconsistent with the attested information, and the inconsistency is relevant to the applicant’s Medicaid eligibility, the LDSS may request further documentation to verify the inconsistency. If upon further review of the information provided, it is determined that the applicant is ineligible, or the applicant fails to provide the requested documentation, proper notice regarding the individual’s eligibility will be sent with a 10-day notice of the change. Further, the LDSS may pursue recovery for any Medicaid benefits incorrectly paid back to the date of the expedited eligibility determination.

For further information regarding the expedited Medicaid application process for individuals seeking immediate need for PCS or CDPAS, please do not hesitate to contact Giannasca & Shook PLLC at (914) 872-6000.