Q. What are resources?
A.Resources are cash or those assets, which can be readily converted to cash, such as bank accounts, life insurance policies, stocks, bonds, mutual fund shares and promissory notes. Resources also include property not readily converted to cash (i.e., real property)
Q. Can I still keep part of my income if I am in a Residential Health Care Facility or in an intermediate care facility for the developmentally disabled?
A.Yes. Under Medicaid you are allowed to keep a small amount for your personal needs. You can also keep some of your income for your family if they are dependent on you. A spouse who remains in the community may also keep resources and income above the levels shown.
Q. What is a "lookback" period?
A. When applying for Medicaid for nursing facility services (Nursing Home), the local department of social services will look at financial transactions to determine whether any assets have been transferred or given away for less than fair market value during a certain time period prior to your application in order to determine if a transfer of assets penalty period needs to be applied. This is known as the "lookback" period. Currently the "lookback" period is 60 months (5 yrs) prior to the month you are applying for coverage of nursing home care.
A penalty period may be imposed for the transfer of non-exempt assets for less than fair market value. The penalty period results in a period of ineligibility for Medicaid coverage of nursing facility services.
A penalty period is not applied for the transfer of your home to the following individuals:
- Spouse
- Child under the age of 21
- Sibling who has an equity interest in the home and has resided in the home for at least one year immediately prior to you entering the Nursing Home.
- Adult child who resided in the home for at least two years, immediately prior to you entering the Nursing Home and who provided care to you which permitted you to reside at home rather than in a medical facility.
For more information regarding the transfer of assets and penalty periods, please contact your local department of social services.
Q. What is a Life Estate? Will it make me ineligible?
A. A life estate is limited interest in real property. A life estate holder does not have full title to the property, but has the use of the property for his or her lifetime, or for a specified period. The life estate is not considered a countable resource, and no lien may be placed on it.
If you or your spouse sell the life estate interest for less than fair market value, it can be considered a transfer of assets and may be subject to the penalty period.
Q. Am I allowed to have a pre-paid burial fund?
A. You may establish an irrevocable pre-need funeral agreement with a funeral firm, funeral director, undertaker or any other person, firm or corporation which can create such an agreement for your funeral and burial expenses. Pre-need burial agreements purchased for certain members of your family on or after January 1, 2011 must also be irrevocable. The pre-need funeral agreement is used towards burial and funeral expenses and is not counted as a resource when determining Medicaid eligibility.
If you (your spouse) do not have an irrevocable pre-need funeral agreement or if the irrevocable pre-need agreement has less than $1500 designated for non-burial space items, you may be allowed to have money set aside in a burial fund. The limit for single individuals is $1500 or $3000 for a couple. Please note, these funds, must be kept separate from any non- burial fund related resources.
Q. If I have an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), can I get my eligibility for these services processed more quickly?
A. Immediate Need for PCS/CDPAS: Informational Notice and Attestation Form (DOH-5786).
If you think you have an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), you may have your eligibility for these services processed more quickly if you:
- have no voluntary informal caregivers able and willing to provide or continue to provide care;
- are not receiving needed assistance from a home care services agency;
- have no third party insurance or Medicare benefits available to pay for needed assistance; and
- have no adaptive or specialized equipment or supplies in use to meet, or that cannot meet, your need for assistance.
If you don't have Medicaid coverage, you may ask to have your Medicaid application processed more quickly by sending in: a completed Access NY Health Insurance Application (DOH-4220); an **Access NY Supplement A (DOH-5178A), if needed; a physician's order (DOH-4359 or HCSP-M11Q or Practitioner Statement of Need (DOH-5779) for services; and a signed Attestation of Immediate Need (DOH-5786) to your local department of social services.
If you already have Medicaid coverage that does not include coverage for community-based long term care services, you must send in an **Access NY Supplement A (DOH-5178A), if needed; a physician's order (DOH-4359 or HCSP-M11Q or Practitioner Statement of Need (DOH-5779) for services; and a signed Attestation of Immediate Need (DOH-5786) to your local department of social services.
If you already have Medicaid coverage that includes coverage for community-based long term care services, you must send in a physician's order (DOH-4359 or HCSP-M11Q or Practitioner Statement of Need (DOH-5779) for services and a signed Attestation of Immediate Need (DOH-5786) to your local department of social services.
If you don't already have Medicaid coverage or you have Medicaid coverage that does not include coverage for community-based long term care services: All of the required forms (see the appropriate list, above) must be sent in to your local social services office or, if you live in NYC, to the Human Resources Administration (HRA). As soon as possible after receiving all of these forms, the social services office/HRA will then check to make sure that you have sent in all the information necessary to determine your Medicaid eligibility. If more information is needed, they must send you a letter, by no later than four days after receiving these required forms, to request the missing information. This letter will tell you what documents or information you need to send in and the date by which you must send it. By no later than 7 days after the social service office/HRA receives the necessary information, they must let you know if you are eligible for Medicaid. By no later than 12 days after receiving all the necessary information, the social services office/HRA will also determine whether you could get PCS or CDPAS if you are found eligible for Medicaid. You cannot get this home care from Medicaid unless you are found eligible for Medicaid. If you are found eligible for Medicaid and PCS or CDPAS, the social services office/HRA will let you know and you will get the home care as quickly as possible.
If you already have Medicaid coverage that includes coverage for community-based long term care services: The physician's order (DOH-4359 or HCSP-M11Q or Practitioner Statement of Need (DOH-5779) and the signed Attestation of Immediate Need (DOH-5786) must be sent to your local social services office or HRA. By no later than 12 days after receiving these required forms, the social services office/HRA will determine whether you can get PCS or CDPAS. If you are found eligible for PCS or CDPAS, the social services office/HRA will let you know and you will get the home care as quickly as possible.
**Note: Individuals with an immediate need for Personal Care Services or Consumer Directed Personal Assistance Services may attest to the current value of any real property and to the current dollar amount of any bank accounts.
Learn about what happens when you apply for Medicaid and how you can request a "fair hearing" if needed.
Q. How long does it take to get Medicaid?
A. Generally, a determination of eligibility must be done and a letter sent notifying you if your application has been accepted or denied within 45 days of the date of your application. If you are pregnant or applying on behalf of children, a determination should be made within 30 days from the date of your application. If you are applying and have a disability which must be evaluated, it can take up to 90 days to determine if you are eligible.
Q. How do I designate or change an authorized representative?
A.When you complete the Access NY Health Care application (DOH-4220) or apply through NY State of Health you may assign a representative. You may allow this representative to apply for and/or renew Medicaid for you, discuss your Medicaid application or case, and/or allow them to get notices and correspondence. You can authorize or change a representative at renewal or anytime in between renewals.
If you recieve Medicaid through your local department of social service (LDSS), you may fill out form DOH-5247 and submit this with your renewal.
If you recieve Medicaid through NY State of Health, you may fill out form DOH-5085 and submit to NY State of Health.
Q. What are my personal privacy rights?
A. Personal privacy rights apply to all Medicaid applications and participants. The New York State Personal Privacy Protection Law and the federal Privacy Act require the New York State Department of Health to tell you what it does with the information, including Social Security Numbers (SSN) that you give the State or sometimes, to your LDSS, about you and your family. The Privacy Act statement is on your application form.
How do I request a fair hearing?
A. If you think any decision about your eligibility determination is wrong, or you do not understand any decision, talk to your application counselor or contact NY State of Health customer service center or your LDSS or HRA, depending on where you applied for Medicaid. If you still disagree or do not understand, you have the right to a Conference and an appeal through a hearing.
If you live anywhere in New York State, you may request a fair hearing or appeal by telephone, fax, online, or by writing. How you make the request depends on who made your eligibility decision; a Local Department of Social Service (LDSS) or HRA, or the NY State of Health.
If your eligibility decision was made at the Local Department of Social Service (LDSS) or HRA:
- Telephone: (800) 342-3334 Please have the notice, if any, available when you call.
- Fax: (518) 473-6735
- Online: Complete and submit the Online Request Form
- In Writing: On the notice, complete the space proveded and send a copy of the notice, or write to:
NYS Office of Temporary and Disability Assistance
Office of Administrative Hearings
P.O. Box 1930
Albany, New York 12201-1930
If your eligibility decision was made by the Marketplace, (NY State of Health):
- Telephone: (855) 355-5777
- Fax: (855) 900-5557
- Online: www.nystateofhealth.ny.gov
- In Writing: New York State of Health
P.O. Box 11729
Albany, New York 12211
Please keep a copy of any notice for yourself.
Follow NYS Medicaid