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.  

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.  The New York State Department of Health (NYSDOH) has issued guidelines for enrollees to use in requesting services from their plans.  NYSDOH Guidelines for Personal Care Services in Medicaid managed care.  

   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. 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 a Conflict-Free Assessment from NY Medicaid Choice and then  choose and enroll in an MLTC plan.

      1. In JULY 2016  a NEW PROCEDURE started for applicants who have an IMMEDIATE NEED for personal care or CDPAP services.  In addition to the Medicaid application with supporting documents,  they may also submit to their local DSS a physician's order for home care, on the State- or County-approved form, plus a new form for Attestation of Immediate Need.  Read about this new process and find the links to download the Attestation form in this article.

         • If Immediate Need Procedure was followed, the Medicaid application must be accepted within seven days, and county DSS must authorize personal care or CDPAP in 12 days.  After 120 days of receiving these immediate need services, the individual will receive a letter from New York Medicaid Choice to select a managed long term care plan in 60 days or client will be automatically assigned to one.

   3. People in the following categories are EXEMPT or EXCLUDED from enrolling in Managed Long Term Care.  They submit a Physician's Order for home care along with their Medicaid application to the local DSS.  

      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 the M11q!  

      2. Traumatic Brain Injury (TBI) Waiver or Nursing Home Transition & Diversion Waiver (NHTDW) participants or applicants.  Write TBI or NHTDW on top of the M11q! 

      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 Services

In September, 2009, State DOH issued a revised Form DOH-4359, which is the standardized Physician’s Order for Personal Care Services for use in the Personal Care Services Program (PCSP) and the Consumer Directed Personal Assistance Program (CDPAP).  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."

 Some counties have received state approval for their own forms rather than using the optional, standardized form.

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

Here are forms for three counties outside of NYC - but please note the authors of this article do not know if these forms are still current.  If you have current forms for these or other counties, please e-mail them to eflrp@nylag.org and give the link to this article.

• Nassau County Physician's Request for Personal Care Aide and Orders to Service Agency (Rev. 7/2020)
• Suffolk County currently uses the DOH-4359 form (confirmed on 9/2016)
• Westchester County Medical Recommendation for Personal Care Services - Form # 1050 (Rev. 10/15)

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.