New Medicaid Procedures in New York

Over the last two years, the state of New York has made several changes to the Medicaid home care program. If you're trying to establish a plan or find care for a loved one, these changes have probably made an already stressful situation all the more chaotic. 

One of the changes that have been made is how someone is assessed for home care eligibility. While there are several ways to apply for home care, the changes to the immediate needs procedure seem to be causing a considerable stir in the Medicaid planning sphere. 

Medicaid Procedures in the Past 

In the past, to check a person's eligibility for Medicaid, they would go to their doctor and have them complete an evaluation and, if needed, an order for home care. In the Bureau's, this form was called a M11-9, in Nassau County, a 517, and in Suffolk County and the rest of New York state, a 4359.

While so many of New York's citizens had grown familiar with the procedures surrounding Medicaid, as of May 16th, 2022, Medicaid procedures have changed except for immediate needs cases. However, immediate needs cases are not immune to the changing Medicaid climate in New York as it shifted again recently on July 1st, 2022. 

What’s Changed in the Assessment Process? 

If you or a family member is considered an immediate needs case, needs will not be assessed by your doctor; instead, they will be evaluated by two independent practitioners in two separate steps: 

• A nurse will do a community health assessment.
• A clinical evaluation will be completed by either a doctor or a nurse practitioner. 

After both parties complete these assessments, the nurse practitioner or doctor will complete a practitioner's order or a PO and send an outcome notice back to the Medicaid office. If approved, Medicaid will use that form to determine a care plan. If the patient is approved for more than 12 hours they’re going to be considered a high needs case and medicaid can create a plan of care. The case has to then be referred to an independent review panel to determine if the care needed can be provided safely at home. 

These medical professionals are arranged through New York Independent Assessor or NYA. After NYA has been called and the request to schedule these two assessments has been made, NYA must schedule these appointments within 14 days. There is an added concern about whether or not these timelines will hold, considering the substantially increased workload on medical professionals and NYA. 

New Procedures in High Needs Cases 

If you or your loved one is approved for more than 12 hours of home care daily, it's considered a "high needs case." Medicaid can then put a plan in place even though the case itself will still be sent to an independent review panel to determine: 

• If the care that is needed can be provided in the home
• If the care that is required can be provided safely in the home

If the review panel comes back and says that the care needed can not be performed safely at home, you’re able to make an appeal. 

These steps might allow New York to minimize the number of eligible patients to receive at-home care. If you feel as though the decision that's been made regarding your Medicaid plan is incorrect, or you are not happy with the outcome of the decision, you can always appeal the decision. 

This new procedure will create a delay in care and ensure that an already complex and confusing process becomes even more complicated. But, at NY Elder Law Group, we'll stand by you during these ever-changing procedures to ensure you or your loved one gets the care they need. 

Contact Us Today 

To hear Lori Somekh’s take on the changes in Medicaid, view her latest video. To contact NY Elder Law Group to see how they can assist you or a loved one with elder law, give us a call or fill out our contact form today.