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New Fast-Track Procedure to Apply for Medicaid Home Care if an "Immediate Need" Exist
New Fast-Track Procedure to Apply for Medicaid Home Care if an "Immediate
Need" Exists for Services
In July 2016, the NYS Department of Health launched a new procedure that
fast-tracks the approval of Medicaid applications for applicants who have
an "Immediate Need" for either personal care or Consumer Directed Personal
Assistance (CDPAP) services. 16ADM-02 - Immediate Need for Personal
Care Services and CDPAP Services (PDF) (Attachment) The State directive
implements a law passed in April 2015, which requires local Medicaid
offices to process and approve a Medicaid application in SEVEN DAYS, and
authorize personal care or CDPAP services in TWELVE DAYS, if there is an
immediate need for these services.
The new procedures are explained in this article. The procedures require
submitting a new Attestation Form that certifies the applicant's immediate
need, along with a "physician's order" for home care, known as the Form
M11q in NYC (other counties have their own forms).
The new procedures are significant for several reasons.
First, when managed long term care became mandatory in 2012, the "front
door was closed" for accessing home care through the local Medicaid
office; the role of local Medicaid offices was now solely to process
Medicaid applications. Once approved for Medicaid, a "dual eligible"
(someone who has Medicaid and Medicare) needed to obtain a Conflict-Free
assessment, then choose and enroll in a Managed Long Term Care plan
(regional lists of plans here). When it passed the 2015 law, the State
legislature was responding to reports of long delays endured in applying
for Medicaid and going through this MLTC enrollment process.
Second, the new law and procedures expedite approval of Medicaid in just
SEVEN DAYS, for those who have an immediate need for these home care
services. We know that meeting this deadline will pose a challenge for
local Medicaid programs and hope that they are given the support they
We salute the New York State legislature and Governor Cuomo for enacting
this legislation, with the leadership of Assembly Health Committee Chair
Richard Gottfried and State Senate Health Committee Chair Kemp Hannon, We
further commend the Department of Health for developing these procedures
thoughtfully, taking into account input from NYLAG and other consumer
advocates. In particular we commend the Dept. of Health for these
features of the procedures that we recommended:
- Married applicants may request spousal impoverishment protections for
their spouses. Before, this budgeting method could only be requested
after the individual enrolled in an MLTC plan, causing needless
impoverishment and confusion. See article for how to request this.
- People who are temporarily in the hospital or who are in a nursing
home may request expedited Medicaid and/or home care so that they can
return home, as shown in the Attestation Form.
- All new applicants for Medicaid are given a fact sheet explaining the
new procedures (page1 at this link)
- Applicants are eligible if their voluntary informal caregivers cannot
continue to provide needed assistance to the applicant. Earlier
drafts of the form had suggested that an applicant whose family is
currently providing informal care does not have an "immediate need,"
even if this informal care cannot continue. Similarly, even if client
is receiving Medicare home care services, which are usually very
limited, she can qualify because Medicare is not providing "needed
assistance" in the amount needed.
Since the procedure is new, be sure to refer to the new ADM when you are
applying, and use LawHelpNY to find your local legal services
organization if you encounter problems or delays. Or you can contact the
ICAN Ombudsprogram regarding delays enrolling into MLTC.