Applying for Medicaid Personal Care Services and CDPAP Outside NYC - 2016 Changes

New York State's Medicaid program covers personal care services and consumer-directed personal assistance services. The model for delivery of those services has, in the years since 2011, gradually transitioned from the local departments of social services, through their Medicaid programs, to different managed care plans. Where to apply for Medicaid, and how to access home care services varies for different populations, with changes in July 2016 and again in 2022.

SEe this article for how to request CDPAP services.     Note there are different procedures depending on whether the individual has Medicare, whether they are enrolled in a Mainstream Managed Care plan, and whether they are under age 18.  

1. People under 65 without Medicare --  Most Medicaid recipients without Medicare under age 65 are enrolled in Medicaid managed care plans. They must access personal care and CDPAP services through their managed care plans.  

   1. How they apply for Medicaid - Most people without Medicare who are under 65 apply for Medicaid on the NYSof Health Exchange.  They are then assigned to a Medicaid managed care plan.  They request that this plan assess and authorize personal care or CDPAP..

   2. Members age 18 and over 

   3. Applicants between age 18-21 may opt for MLTC instead of mainstream Medicaid managed care if their disability is such that they would otherwise qualify for nursing home placement. Even if they applied for Medicaid on the  NYSof Health Exchange, they must request that their Medicaid case be transitioned from the Exchange to the Local DSS.  

2. People over age 65 without Medicare and most adults age 21+ with  Medicare apply for Medicaid at their local county Dept. of Social Services.   How they then access  personal care or CDPAP depends on various factors.  

   1.  All must first apply for Medicaid at their local county Dept. of Social Services (DSS).  They submit:

      • Medicaid application (DOH-4220)((other languages and formats at this link); 

      • Supplement A  (DOH-5178A)(other languages and formats at this link);

      • All supporting documents, including verification of all financial resources..  See this Troubleshooting guide for tips to avoid delays in  applications for people who will have a Spend-Down.

   2. Adults Age 21+ with Medicare (Dual Eligibles) -   Once approved for Medicaid, unless they are in one of the categories exempt or excluded from MLTC, they must request an Independent  Assessment from NY Independent Assessor and then  choose and enroll in an MLTC plan.

      1.  Since JULY 2016 applicants who have an IMMEDIATE NEED for personal care or CDPAP services may request CDPAP or Personal Care when they file  the Medicaid application   to their local DSS.   Read about this process and find the links to download the forms in this article

   3. People in the following categories are EXEMPT or EXCLUDED from enrolling in Managed Long Term Care.  Once they have Medicaid approved,  they request an Independent Assessment from NYIAP..  If approved by NYIAP, they submit  the Outcome NOtice from NYIAP to their local DSS/HRA.   

      1. Anyone actually receiving hospice services is not eligible for MLTC and may apply to the HRA Home Care Services program for personal care/home attendant/CDPAP services to supplement hospice care.  Write "HOSPICE PATIENT" on top of submission of the NYIAP Outcome Notice to the DSS. 

      2. Traumatic Brain Injury (TBI) Waiver or Nursing Home Transition & Diversion Waiver (NHTDW) participants or applicants.  Write TBI or NHTDW on top of the submission of the Outcome Notice to DSS! 

      3. People seeking HOUSEKEEPING (personal care Level I) services, limited to 8 hours/ per week. 18 NYCRR 505.14(a).  These are for assistance with IADLs (instrumental activities of daily living, or help with shopping, cooking, housecleaning, laundry) as opposed to ADLs (activities of daily living, or help with personal needs such as bathing, dressing, toileting, mobility transfer)

      4. People in the OPWDD (Office of Persons with Developmental Disabilities) Waiver are EXCLUDED from MLTC and must get services through HRA.Where and How to Apply for Medicaid and Home care - people exempt or excluded from MLTC

 About the Physician's Order for Personal Care or CDPAP Services

The NY Independent Assessor replaces the requirement for a PHysician's Order for adults applying for personal care or CDPAP.   However, children under age 18 seeking CDPAP services, and for adults who were already receiving personal care or CDPAP when NYIAP was implemented will NOT be assessed by the NY INdependent assessor on renewals - at least as of now.  Check here for updates.  For the time being, children under 18 applying for CDPAP and adults going through renewal of their CDPAP may be asked to submit a Physician's Order.  Outside of NYC, use Form DOH-4359,  See NYS DOH GIS 10LTC006 - Physician's Order for use in the Personal Care Services Program and the Consumer Directed Personal Assistance Program with its attached DOH-4359.   The directive makes the new form optional for counties, which may instead revise their own forms to "...contain all of the elements reflected in this revised form."

 NYC HRA received state approval to continue using the  Form M-11q - Medical Request for Home Care (12-9-014).

The doctor who signs the   physician's order must be enrolled with the NY State Medicaid program in order for Medicaid to pay for services that they prescribed, ordered or referred.   See this article

Helping a doctor to complete the medical request form can be tricky, because many forms use terms that are not universally understood by doctors.  In addition, there are some details that are very important to assessing the need for home care, but which are not solicited on the form.  To help you understand how to complete a successful medical request form, we have written a memo called Q-Tips.  The Q-Tips memo is also available in Spanish.  This memo is written specifically with regard to the NYC medical request form, the M-11q, but most of the information should be applicable statewide.  Keep in mind that this form is a medical document - non-doctors can assist in its completion, but in the end, a doctor must sign and certify that the contents are true.

This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.