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NEW YORK INDEPENDENT ASSESSOR PROGRAM (NYIAP) - How Medicaid Home Care Eligibility is Assessed

Article ID: 253
Last updated: 23 Apr, 2026
Views: 7107
Posted: 11 Dec, 2024
by Valerie Bogart (New York Legal Assistance Group)
Updated: 23 Apr, 2026
by Valerie Bogart (New York Legal Assistance Group)

What is the NY Independent Assessor Program? The Basics 

In 2020, a NYS law was enacted that required an "independent assessor" to assess the need for and approve  personal care, CDPAP, and Managed Long Term Care (MLTC) enrollment.   For MLTC, this was not new because the COnflict-Free Eligibility and Enrollment Center (CFEEC) already existed, which approved eligibility to enroll in an MLTC plan.  NYIAP replaced the CFEEC for MLTC.  But for personal care and CDPAP, NYIAP was a totallyh new concept.  Before, eligiblity for these services was determined by the Local Dept. of Social Services (HRA in NYC) or by a Mainstream Medicaid managed care plan (for those without Medicare who are required to enroll in these plans). Now, the New York Independent Assessor program would make these determinations.  

The program was rolled out gradually in 2022 but is now in effect as described below.   for more info see Feb. 8, 2023 webinar recording here and NYLAG's slide deck from the webinar) 

These three categories of consumers must request an assessment from NYIAP:

  1. anyone seeking to enroll in an MLTC plan (started May 16, 2022),

  2. a mainstream managed care member who is requesting NEW personal care or  CDPAP services (started May 16, 2022 for standard time requests and Dec. 1, 2022 for expedited requests) or

  3. those who request NEW personal care or CDPAP services from the local Dept. of Social Services (LDSS), which includes: started May 16, 2022 for:

    1. People who are sxempt or excluded from MLTC or mainstream managed care, such as people in the OPWDD waiver or in home hospice, which have been required to use NYIAP for standard applications a

      • See HRA Alert on 05/13/22 re NYIA.

    2. "Immediate Need requests" for personal care and CDPAP - started Dec. 1, 2022 

      •  DOH directive GIS 22 MA/09 - Implementation of Assessments Conducted by the New York Independent Assessor (NYIA) Based on an Immediate Need for PCS/CDPAS (PDF) (11/16/2022)

What assessments are NOT conducted by NYIA?

As of Apirl 2026, NYIAP is NOT used for assessments for people who are already receiving personal care or CDPAP services who are requesting an increase in hours -- whether from an MLTC plan, the local Dept. of Social Services, or a mainstream managed care.  Nor is NYIAP used  for routine annual reassessments, which are still conducted by the MLTC plan, the local DSS, or the managed care plan.  The State plans to expand NYIAP to include these mid-year assessments at some point. 

See  https://www.health.ny.gov/health_care/medicaid/redesign/nyiap/2023-10-03_rollout.htm 

NYIA is NOT REQUIRED for anyone CURRENTLY receiving Medicaid Personal Care or CDPAP services - such as those receiving Immediate Need services from their Local DSS and after 120 days are told by NY Medicaid Choice that they must select an MLTC plan or they will be enrolled in one.  However, if they try to enroll in an MLTC plan BEFORE passage of 120 days, they will be required to go through NYIA.    DOH EMAIL with this policy on file with NYLAG if needed.  Email vbogart@nylag.org 

STEPS OF THE NYIAP ASSESSMENT PROCESS

Consumer/rep calls NYIA at 1-855-222-8350 to schedule TWO assessments:  -- Consumers can appoint a representative to talk to NYIA on their behalf. See form and fax number to submit it here.   

  1. Independent Assessment (IA)  by a Nurse from NY Medicaid Choice -- this is the same Uniform Assessment that NY Medicaid Choice has long done for the Conflict Free Eligibility and Enrolllment Center.  Now, this will be the sole nurse assessment.  The plans and Local DSS must use this assessment instead of doing their own.  This assessment will first determine if the individual meets the new minimum-ADL requirement, if this is a new application.  

    • "(iii) The independent assessment must assess the consumer where the consumer is located including the consumer’s home, a nursing facility, rehabilitation facility or hospital, provided that the consumer’s home or residence shall be evaluated as well if necessary to support the proposed plan of care and authorization or to ensure a safe discharge. This provision shall not be construed to prevent or limit the use of telehealth in the assessment of a consumer.."   18 NYCRR 505.14(b)(2)(I)(c);  505.28(d)(1)(iii) 

    • After Sept. 1, 2025, NYIAP will assess whether the consumer meets the new minimum ADL thresholds.   See more here.   NYIAP should inform the consumer that if they Alzheimer's disease or dementia they must submit by fax to 917-228-8601 a new form signed by their physician  -- Alzheimer's Disease or Dementia Form (DOH-5821).  https://nyindependentassessor.com/en/what-should-i-do-if-i-have-an-alzheimers-disease-or-dementia-diagnosis

    • This form can be faxed with a cover sheet that also has the NYIAP fax number.

    • The diagnosis must be made by a physician or D.O. - who need not be a NYS Medicaid provider.  With this form, the consumer can qualify if they need supervisory assistance with two ADLs, rather than limited assistance with physical maneuvering with 3 ADLs.  MLTC Policy 25.04:  and  25 OHIP/ADM - 03 - New Minimum Needs Requirements for MLTC, Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS) Eligibility 

  2. Independent Practioner Panel (IPP) or C.A. - exam by PHYSICIAN, physician’s assisant or nurse practitioner  from NY Medicaid Choice, who prepares a Physician's Order (P.O.)   In MLTC, this is NEW.  Doctor’s orders (M11q) had not been required.

    • Note: the IPP/CA may wish to clarify information about the consumer’s medical condition by consulting with the consumer’s provider’s.  The consumer must give provider’s permission to do this.  NYIA has its own form for this purpose.  See NYLAG fact sheet explaining how to complete and submit this form.

    • TREATING PHYSICIAN’S ROLE IN PRESCRIBING PERSONAL CARE OR CDPAP IS REPLACED by this Independent Practitioner panel. 

      Personal care and CDPAP services must be prescribed by a qualified independent physician selected or approved by DOH. The law authorizes using Maximus (NY Medicaid Choice) instead of procuring a new contractor.

      Side note: Aside from the lack of familiarity a contract physician would have with the consumer’s condition, compared to a long-time trusted physician, and the lack of specialization in the consumer’s particular diagnosis, this requirement adds even more delays to applying for services.  

After the 2nd Notice, NYIA sends an Outcome Notice  - which will say:

  1. IF  the consumer is seeking to enroll in an MLTC plan,  Outcome Notice says whether or not they are eligible to enroll in MLTC.   

  • Criteria flr MLTC if adult Dual Eligible -

    1. need assistance with community-based long term care for more than 120 days AND

    2. starting Sept. 1, 2025 - must meet the new MInimum ADL critieria -  need for "limited" assistance  with physical maneuvering" for THREE  Activities of Daily Living (ADLs) or  supervisory assistance with TWO ADLs for people diagnosed with Alzheimer's disease or dementia.  

    3.   "MLTC plans should not deny enrollment for an individual determined medically unstable, unless the MLTC plan is unable to provide any other CBLTSS the individual is eligible to receive."    MLTC Policy 25.04: Minimum Needs Requirement Update to the Eligibility Requirements for Managed Long Term Care Enrollment - 6.30.2025

    4. If do not have Medicare, or if age 18-21, must also need a "nursing home level of care," meaning a score of 5 on the assessment. 

  • If Outcome Notice says not eligible for MLTC, consumer may request a Fair Hearing. The Outcome Notice does not specify WHICH criteria are not met - the 3 ADL standards or not needing any services for 120+ days.  If the notice says medical condition is unstable, however, MLTC may not deny enrollment unless they determine that consumer is not eligible for other services, such as private duty nursing.  MLTC Policy 25.04.  

  • If they are in a Medicaid managed care plan  or are exempt or excluded from  MLTC, the Outcome Notice says whether they are medically stable to receive home care and, after 9/1/25, whether they meed the new minimum ADL thresholds. Even if medical condition is unstable, plan should assess for private duty nursing or other services..    If they are in a mainstream managed care plan, they contact their plan to further evaluate and approve or deny personal care or CDPAS.  If they are not in a mainstream plan and are excluded or exempt from an MLTC plan, they contact their local LDSS which then evaluates them and approves or denies personal care or CDPAS.  In NYC - see where to go here. 

3rd Assessment must be scheduled if either an MLTC plan, a mainstream managed care plan or the LDSS determine that the indivdiual needs more than 12 hours/day on average, then they must refer it back to NY Medicaid Choice for  a third assessment - the Independent Review Panel in next section below. (Section 11).

  1. INDEPENDENT REVIEW PANEL (IRP) - The 2020 MRT II law authorizes DOH to adopt standards, by emergency regulation, for extra review of individuals “whose need for such services exceeds a specified level to be determined by DOH."  DOH's regulations draw this line at those needing more than  12 hours/day of home care on average. The assessor will review whether the consumer, “with the provision of such services is capable of safely remaining in the community in accordance with the standards set forth in Olmstead v. LC by Zimring, 527 US 581 (1999) and consider whether an individual is capable of safely remaining in the community.” (Sec. 2, 20).  Again, this is a panel run by New York Medicaid Choice. 

Side note: While we are pleased to see the seminal U.S. Supreme Court Olmstead decision cited specifically in the law, the entire notion of vetting a high-hour case to consider whether the individual is “capable of safely remaining in the community” raises huge Olmstead concerns. Even now, before these changes are implemented, those who need high hours such as 24-hour care must fight decisions by MLTC plans that they must be permanently placed in a nursing home.

Who is the arbiter of “safety?” What about the consumer’s autonomy – their right to the “dignity of risk” in choosing to accept some risks that may exist in the community in order to live at home as they choose? And their right to the medically necessary supports to meet their daily needs? Invoking concerns about “safety” is an old pretext for denying services–a pretext that the Americans with Disabilities Act (ADA) was enacted to combat.

CONTACTS - How to Request NYIAP Assessment or copy of the Assessments, Submit a Power of Attorney, etc.

Form to Designate a Representative - REVISED - now separate from the Information-Sharing  Consent Form

  • At the request of consumer advocates  including NYLAG and Medicaid Matters NY, a NEW form for consumer to designate a representative was posted on NYIA website. See new form here posted on the NYIA website page on representatives.   The site now says the signed form can be FAXed to  (917) 228-8601 or mailed - address on website. 

  • This form is now separate from the Information-Sharing Consent form,  which consumers have complained is  difficult to use.   See NYLAG fact sheet explaining how to complete and submit the consent form, which allows NYIA to contact a consumer’s doctors and other medical providers as they deem necessary for the assessments.  See NYLAG fact sheet explaining how to complete and submit the CONSENT form.  NYLAG is raising concerns with DOH about this form, since it is difficult to complete and submit. and since consumers should  have other easier ways to designate a representative.

NYS Websites, Policies & Procedures for NYIAP

NYS DOH POLICIES:

NYLAG Slide decks and webinars on NYIA  and the New ADL Thresholds 

STATE REGULATIONS ON INDEPENDENT ASSESSOR AND NYLAG COMMENTS 

Final state regulations  on Personal Care and Consumer-Directed Personal Assistanc (CDPAP) were  posted on the NYS DOH website on August 31, 2021, published in the NYS Register on Sept. 8, 2021.  Direct link to regulation is here.   The regulations have an effective date of Nov. 8, 2021, but they will not all be implemented on that date.   NYLAG was disappointed that the final regulations were virtually same as the  proposed state regulations to which NYLAG and other organizations submitted comments in March 2021.  Most of our recommendations were rejected.   

On Dec. 13, 2021, DOH posted an ADM and MLTC policy on some minor changes in the state regulations, but not on the major new Independent Asssessor procedures.   See 21 ADM-04 & MLTC Policy 21.06 - announce changes including:
  • Reassessments now are annual not every 6 months
  • CDPAP:  only one FI per consumer; designated rep for non-self directing consumer must be present at all assessments, new agreement between consumer/rep and LDSS/plan
  • M11q/physician’s order may be signed by Nurse practitioner, physician’s assistant, Osteopath – not just MD
  • Tweaks permitted reasons for reductions in MLTC Policy 16.06:
  • Tweaks policy on “safety monitoring” under NYS DOH GIS 03 MA/003  and MLTC Policy 16.07

On Nov 8, 2021, State DOH  posted a webinar clarifying which of the recent personal care and CDPAP regulation changes will go into effect on Nov. 8, 2021. (Recording) - (Web) - (PDF) (11.8.21). 

  1. WHAT IS DELAYED:  The new minimum of 3 ADLs (2 if have dementia)  for home care and MLTC, and the new Independent Assessor procedures,werel NOT implemented yet, but later the Independente Assessor  

  2. WHAT STARTS NOVEMBER 8, 2021 -  The regulation  cuts back on consumer rights after a "Transition Period."  These changes will make it easier for a plan to reduce hours after a consumer is required to transition to a new MLTC plan.  This could be after their old plan closes, or after they received Immediate Need services for 120 days, or after they first became enrolled in Medicare and had previously received home care from a "mainstream" Medicaid managed care plan.  Read more about these transition rights and how they are changing along with advocacy tips, here.

NYLAG COMMENTS Submitted on State Regulations & Policies  to Implement the Changes -

  • INDEPENDENT ASSESSOR -  NYLAG, alone or as part of coalitions, has sent many letters to DOH with questions and comments about the NYIA implementation.

    • On Oct. 27, 2022, Medicaid Matters NY, and  theCoalition to Protect the Rights of New York’s Dual Eligibles joined with associations that represent Managed Long Term Care plans and home care providers to send a joint letter to the Hochul administration to air concerns about and demand slowdown of implementation of the New York Independent Assessor.  The letter can be downloaded here.  It asks that the NYIA expansion to include Immediate Need requests and expedited mainstream Medicaid managed care requests, slated for Dec. 1, 2022, be halted until the myriad delays and problems with this new assessment system improve.    

    • On May 3rd, 2022, NYLAG sent these questions and comments about the new policy directives. 

    • Mar. 25, 2022 - NYLAG sent a second set of comments and questions   about Topics 2 and 3 presentations on DOH NYIA website. 

    •  Feb. 2, 2022 - NYLAG sent DOH questions  and comments on 2/2/2022 about the 1st 2 sets of Powerpoints posted 12/2021 and 1/14/22. 

    • Dec. 15, 2021 --NYLAG and Medicaid Matters NY jointly sent Dec 2021 letter to DOH with concerns about implementation, posted here with a Jan. 6, 2022 update.   DOH has acknowledged at a meeting with Medicaid Matters NY on Jan. 4, 2022  that NY Medicaid Choice lacks the capacity to conduct these assessments - in part due to nursing shortage aggravated by COVID.  

  • On Sept. 14, 2020, NYLAG submitted Comments posted here  to  the  proposed state regulations that would implement  the Home Care Eligibility Changes and Changes in Assessments. 

  • On Oct. 29, 2020, NYLAG submitted comments to the State's proposed State Plan Amendment that would implement the new ADL requirements for all personal care and CDPAP, whether obtained through the local Medicaid office, an MLTC or Mainstream managed care plan 

  • On Dec. 24, 2020, NYLAG submitted comments to the State's proposed amendment of the 1115 waiver that governs the MLTC program, that would restrict eligibility to enroll in MLTC plans to those who meet the new 2 or 3 ADL criteria. 

  • On March 13, 2021, NYLAG submitted comments to the 2nd round of proposed state regulations that implement the new ADL criteria and Independent assessor procedures.  

  • On March 26, 2021 -  With the April 1st NYS Budget deadline looming,  NYLAG, Legal Aid Society, Empire Justice Center and other organizations sent a letter calling for steps to ensure access to home care - and to avoid nursing home placement - including repeal of the ADL thresholds enacted in last year's budget

Views: 7107
Posted: 11 Dec, 2024 by Valerie Bogart (New York Legal Assistance Group)
Updated: 23 Apr, 2026 by Valerie Bogart (New York Legal Assistance Group)
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