By: Elizabeth L. Schalk, Medicaid Supervisor
The following are current Medicaid home care programs in New York.
Personal Care Aide Program (PCS)
The Personal Care Aide Program provides for custodial level (assistance with the “Activities of Daily Living” or ADL’s) home care services and is not covered by Medicare. For the purposes of Medicaid, it is a “prior approval” program. This means that Medicaid financial eligibility as well as the need for home care services must be approved by The Department of Social Services (DSS) before Medicaid will authorize the home care services for the applicant.
To be eligible for this program, the applicant must require custodial care and need partial or total assistance with a minimum of two ADL’s. These are defined as feeding, tolieting, grooming, bathing, ambulating and transferring. The home attendant may perform personal care functions and assist only with ADL’s.
Hours granted could be from four hours per day up to round-the-clock (split shift) care. Twenty-four hour sleep-in care means the home attendant assists the client during the daytime hours, and is available to assist the client once or twice during the night. If the applicant is awake more than once or twice they may be eligible for split shift where one aide is on duty at night and another during the day, each working twelve hour shifts. It is difficult to obtain more than four to eight hours per day on this program from the counties.
The current physician must complete and sign a Physician’s Order form. Once this form has been completed it is only good for thirty days and an application must be made prior to this form expiring.
Consumer-Directed Personal Assistant Program (CDPAP) Or Consumer-Directed Program
This program is the same as the above except that an adult child or family member (consumer) may direct care of a patient. The “consumer” hires, trains and supervises the home attendants who are allowed to perform tasks which ordinarily would require the skills of a home health aide or even a licensed practical nurse. The home attendant cannot be an immediate family member and the “consumer” will be trained by the vendor, assigned by the county, as to what forms must be completed, what documentation for employment is required and all duties and responsibilities that must be performed. They will be responsible for keeping personnel records, completing payroll forms, arranging the schedules of the home attendants and having back-up for the home attendants that cannot make their shifts along with training the home attendants in the care of the applicant and all other supervisory needs for the applicant’s home care. They must be able to make educated choices as to the type and quality of services. This program is available whether the person is on personal care services, the Lombardi Program, CHHA services, AIDS home care services and private duty services.
The above two programs require a Medicaid application, three current months of financial statements, all income award letters, common documents, written verification of health insurance premiums, copy of current year’s federal and state tax filings and no payment for services during the processing of the Medicaid application will be reimbursed to the client. The applicant may use a Pooled Trust if it is in place upon application. If applying for any borough in NYC, the application for the PCS program goes to the Community Alternative Systems Agency (CASA) assigned for that area and for the CDPAP it goes to the assigned office for that program. There are no transfer penalties for this program.
Certified Home Health Aide Services (CHHA)
This program provides home health services under both Medicare and Medicaid. Medicaid home health services must be provided pursuant to a physician’s written plan of care. They do not require prior approval from Medicaid and Medicare will usually cover the cost of CHHA services for about forty-five days upon a person’s discharge from the hospital. The home health aide carries out health care tasks under the supervision of a registered nurse or licensed therapist and may also provide custodial care and assistance with the individual’s ADL’s. They may preform skilled tasks, such as preparation of meals in accordance with complex modified diets; assistance with tube feedings; placement of spray or spoon of medication in patient’s mouth, but only if the patient is self-directing; give medicated baths; performance of skin and nail care; dressing changes on stable skin surfaces; monitoring vital signs; and caring for mature and stable colostomies and tracheotomies. Applicants for CHHA services apply directly to the CHAA, not DSS.
***Please note that this program may no longer be offered due to budget cuts.
Lombardi Program (long-term home health waivered program or nursing home without walls program)
This program provides skilled services and “waivered” services, but they also provide personal care aide services to their clients when needed. A waivered service is a service which is not ordinarily covered by Medicaid because it is not “medical” unless a state obtains special permission from the federal government to cover those services as part of a special package. Some of the “waivered” services would be home maintenance tasks; transportation to social events; congregate/home delivered meals; respite care; social day care; and social work services.
In this program the cost of all services for each client may not exceed 75% of the cost of nursing home care for that applicant. The applicant must be eligible for nursing home services and the budgeting is figured on the standards for home care with spousal impoverishment budgeting. There are no transfer penalties and this program may be applied for through the CHHA provider or local DSS.
***Please note this program is being financed on a trial basis until the federal government extends the special permission for waivered services or notifies NYS that it will no longer grant permission for waivered services.
Nursing Home Transition and Diversion Program (NHTD)
This program is an alternative to traditional home care services. Applicants will receive nursing home type services at home. The NHTD program is budgeted under community Medicaid and the applicant may use a Pooled Trust if enrolled and accepted prior to application. There are no transfer penalties for this program. This is a waiver program and the applicant must be capable of living in the community; eligible for nursing home level of care; authorized to receive Medicaid Community-based Long-Term care; at least eighteen years of age; and considered part of an aggregate group that can be cared for at less cost in the community than a similar group in a nursing home. The program offers service coordination, assistive technology, community integration counseling, congregate and home-delivered meals, moving assistance, peer mentoring, respiratory therapy and respite services. It does not offer medical services such as personal care aide and the applicant cannot be on any other Medicaid program for home services.
Applications must go through the local Regional Resource Development Centers (RDCC). The applicant, social worker at the nursing home, or family member may call the RDCC and a nurse will be sent to complete an assessment to decide if the applicant will qualify for this program. The RDCC is responsible for interviewing potential applicants, reviewing Service Plans, maintaining regional budgets and issuing notices to applicants and participants relevant to their participating in the waiver program. There are a limited number of entries for all of NYS on this program and waiting lists are very long. Spousal impoverishment budgeting is not allowed for this program.
Medicaid Managed Long-Term Care (MLTC)
The applicant must be already accepted to the Medicaid program for long-term care and may then change to a Managed Care plan voluntarily There is a table of all of the MLTC Plans in NYS available in the Medicaid Supervisors Office.
Pace for All-Inclusive Care for the Elderly (PACE)
This program provides a comprehensive system of health care services for members age fifty-five and older who are otherwise eligible for nursing home admission. The objective is to provide a fully integrated package of care for seniors while allowing them greater independence by avoiding institutionalization. Both Medicare and Medicaid pay for this program and anyone eligible for Medicaid may participate in a PACE by paying a monthly premium equal to the Medicaid capitation amount. PACE members are not allowed to go “out of plan” to receive services. Most participants are dually eligible for Medicare and Medicaid. Medicaid coverage for PACE is under community coverage with community-based long-term care, meaning they must provide three months of current financial statements, common documents, etc. There are no transfer penalties for this program but spousal impoverishment rules do apply to PACE enrollees. There are 5 PACE sites that operate in NYS with only one for the NYC area. There is a table of the 5 PACE sites in NYS available in the Medicaid Supervisors Office. This program is not for someone who needs aide care in the home.
Assisted Living (AH-ALP)
There are limited assisted living beds paid for by Medicaid in NYS. The application process follows the same regulations as the community coverage with community-based long-term care, meaning they must provide three months of current financial statements, common documents, etc. There are no transfer penalties for this program but spousal impoverishment does apply to PACE enrollees. The Medicaid Supervisor has a list of all available assisted living centers that are Medicaid contracted. Beware that some assisted livings tell the clients they will accept Medicaid, but this is only for their medical bills after Medicare pays, it is not for the room and board.
Please note that all of the above programs will not roll-over to a chronic care application. A chronic care application for nursing home coverage will be a new application requiring 60 months of financial documentation for trusts and all personal accounts from 02/01/06 – forward. However, someone with chronic care coverage may roll-over their coverage to one of the above programs if they return home.