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December 3, 2021


Understanding the Major Change of Medicaid Eligibility and Lookback in NY State

Eligibility for Medicaid.Last month, New York finally adopted regulations implementing budget cuts from the state’s 2020 budget. Several of these regulations imposed a major change in Medicaid eligibility. These regulations also introduced a “lookback” period into New York’s state’s Medicaid program. While many agree that reforms to New York state’s regulations were necessary, the reception to the new rules is mixed. The new lookback period promises to heighten the complexity of the already complicated New York state Medicaid program. So a detailed review of the changes and the current status of the program is in order.

Understanding these changes is essential for those who seek to assess their Medicaid eligibility in New York State. However, the complexity of the Medicaid process can be overwhelming for those unfamiliar with Medicaid law. Therefore, we recommend that you contact a qualified New York Medicaid and elder legal matters attorney as soon as possible to discuss your situation.

Understanding Medicaid and New York State’s Medicaid Program

Before discussing the changes to Medicaid eligibility, a brief refresher on Medicaid is needed for those of our readers who are unfamiliar with the program. Medicaid, like its well-known sister program Medicare, is a government program designed to provide medical assistance to people with lower incomes. However, unlike Medicare, Medicaid involves a partnership between the federal government and state governments. If the state’s program meets certain federal requirements, the federal government provides part of the program’s overall funding. Aside from these basic federal requirements, states are free to craft their own rules on who is eligible for Medicaid. As of 2021, all 50 states had a Medicaid program of some kind.

Specific Major Changes of Medicaid Eligibility and Lookback in NY State

Unfortunately, Medicaid eligibility was restricted by New York state’s new changes. For instance, one change limited the availability of services through the state’s Consumer Directed Personal Assistance Program (CDPAP). As the name suggests, CDPAP is a Medicaid program that allows eligible consumers to recruit and direct their own home care workers. One of CDPAP’s fundamental requirements is that a consumer must require home care. Because of one of the new changes, consumers must provide evidence that they need more assistance with daily activities. In particular, applicants must now demonstrate that they need assistance with three Activities of Daily Living (ADL) or dementia to qualify for CDPAP.  Before 2020, applicants needed to demonstrate a need for assistance with only two ADLs.

In addition, home care services must be prescribed by an independent physician and approved by an independent assessor. Both the physician and assessor must have a contract with the New York Department of Health (NYDOH).  Before 2020, a customer could use their own physician to prescribe home care services. Whether the physician was under contract with NYDOH was irrelevant.

Yet another change involves customer education regarding CDPAP. New Medicaid applicants in New York will no longer be informed that CDPAP is an option for their needs. All of these changes make it significantly more difficult for customers to qualify for CDPAP. Fortunately, individuals who already receive home care through CDPAP will not need to meet these new standards. Instead, they are “grandfathered” in.

The Lookback Period: Arrival and Implementation

A lookback provision gives the state the power to review the financial statements of anyone who is applying for home health care, private nurses, and other kinds of assisted living.  By “looking back” at these records during the time period prior to their Medicaid application, the state can limit applicants’ eligibility. If the state discovers any monetary gifts or uncompensated transfers to an applicant during the lookback period, it may delay or deny a Medicaid application.

Medicaid is fundamentally a program that is based on financial need. Therefore, the way of measuring who is in financial need, and who is not in financial need, is a critical issue for potential Medicaid recipients. That said, the lookback concept is a newer one, at least in the context of New York state’s Medicaid program. In fact, before 2020, there was no lookback period in New York state’s Medicaid program. Thanks to these changes, there will now be a 30-month lookback period.

Authorities will base the delay of an applicant’s eligibility on a calculation of the regional medical services rate. For instance, imagine a Medicaid applicant applying for at-home care services who received uncompensated transfers totaling $15,000 over the two years preceding their Medicaid application. If the going rate for an at-home care nurse is $7,500 a month, then the applicant’s Medicare eligibility will be delayed for at least two months. As a result of the lookback, many individuals who would otherwise qualify for Medicaid will see their Medicaid eligibility delayed or canceled because of an unrelated financial transfer made sometime before their application.

There is some good news, however. Thanks to the Families First Cares Act (FFCA), which prohibited states from restricting Medicaid eligibility during the pandemic, New York’s lookback period has been delayed. As of the time of writing, it is likely that the lookback provision will come into effect sometime in the middle of next year.

Contact an Elder Law and Medicaid Legal Matters Lawyer Right Away

Understanding the recent major changes to Medicaid eligibility and lookback in New York is essential. If you want to learn more about these changes or plan to apply for Medicaid soon, you should contact an attorney.

At the Law Office of Andrew M. Lamkin, P.C., we are standing by to answer all of your questions and assist you with your Medicaid application. Many people wrongly believe that they are ineligible for Medicaid. Yet the truth is that we can work with you to help you qualify for benefits when you need them. Our lawyer has extensive experience dealing with the complexities of Medicaid law and understands the importance of providing income for your family. Give us a call at 516-605-0625 to set up a consultation. You can also contact us online if you prefer.