New York State’s Medicaid Homecare program pays for in-home personal care services. New York’s program has long been the best in the country. One underlying policy behind the program was that people should have every opportunity to remain in the community. A community focus provides two benefits: the social benefit derived from keeping people independent and connected to their friends and families and the cost savings to the state and federal government of paying for at-home care versus care in a nursing home.
In July 2020 we reported on significant Medicaid Homecare changes in the New York State 2020 Budget Bill. While many of the 2020 Budget Bill changes are not yet in place, several changes have been implemented, and others are on our doorstep.
Increased Threshold for New Applicants
Starting September 1, 2025, there will be tougher rules for new homecare applicants based upon their need for assistance with activities of daily living (ADLs). ADLs are the daily activities we all need to live, and they include bathing, dressing, eating, walking, using the bathroom, or getting in and out of bed.
Under the new rules, will have to prove they need help with at least three ADLs to qualify. People with dementia or Alzheimer’s will face a slightly lower threshold, needing to prove they need help with at least two ADLs.
The restrictions tightly define the ADLs that will be considered:
- Bathing (getting in/out of the tub or shower, washing the body — not including back or hair)
- Personal hygiene (brushing teeth, combing hair, washing face)
- Dressing
- Walking indoors on the same floor
- Moving between locations indoors on the same floor
- Getting on and off the toilet
- Using the toilet/commode and cleaning up afterward (including changing incontinence pads and adjusting clothing)
- Bed mobility
- Eating
Such may cut off access to essential . These restrictions will be especially devastating for people with traumatic brain injuries, developmental disabilities, or blindness, who do not meet the three ADL requirements but need assistance to live safely in the community.
State officials defend the strict criteria as necessary to the sustainability of Medicaid’s home care program and to prioritize resources for those with the highest level of need.
Legacy Status
The new eligibility rules will only apply to new applicants after September 1, 2025. Typically, current Medicaid Homecare recipients will not be subject to the new restrictions. People receiving Medicaid Homecare services before the September 1 implementation date can have “Legacy Status” under the old rules. In other words, they can continue to receive care even if they do not meet the new three-ADL (or two-ADL for dementia) threshold, if they maintain continuous eligibility.
Standard and Exception
Medicaid Homecare recipients who do not have Legacy Status will need to demonstrate a need for assistance with physical maneuvering and three ADLs. Medicaid Homecare recipients who do not have Legacy Status but have dementia or Alzheimer’s disease can continue to receive care if they can demonstrate a need for supervision with at least two ADLs.
Next Steps
- If you are financially eligible for Medicaid benefits and only need help with one ADL, submit your application immediately. The process can take weeks, so filing as soon as possible increases the chance of approval before September 1.
- Once approved, keep your Medicaid coverage active. Any lapse in eligibility or gap in service could cause you to lose Legacy Status, subjecting you to the stricter rules. Losing services after September 1, 2025, could mean you have to requalify under the new standard.
- If you do not currently need homecare services, this is the time to speak with an attorney to create a comprehensive long-term care asset-protection plan, to reduce the risk of future ineligibility.
