Medicaid covers medical expenses for people who have low income with some services requiring co-payments. If eligible this can include long-term care in your home, or at a nursing home. This program covers many more services than are covered by Medicare, such as personal care (bathing, dressing, etc.). As the program is both federal and state run, there are particular minimums that each state must abide by in covering groups of people and services, but the states are free to cover any additional groups and services. In New York State, there are no co-payments for home health care services, personal care services, or long-term home health care services.

After qualifying for Medicaid, additional requirements need to be met to receive long-term care as determined by your state. In New York, you need to contact your Local Department of Social Services (LDSS) to verify your eligibility. A directory listing of each county can be found here

Eligibility

There are general and financial requirements to meet Medicaid eligibility. 

Under most circumstances, you will need to be one of the following:

  • Be age 65 or older
  • Have a permanent disability as that term is defined by the Social Security Administration
  • Be blind
  • Be a pregnant woman
  • Be a child, or the parent or caretaker of a child

Additionally, other requirements include:

  • Be a U.S. citizen or meet certain immigration rules
  • Be a resident of the state where you apply
  • Have a Social Security number

After meeting the general requirements above, you will need to have income below certain thresholds. Your income includes regular benefit payments (such as Social Security retirement or disability benefits), veterans’ benefits, pensions, salaries, wages, interest from bank accounts and certificates of deposit, and dividends from stocks and bonds. See the table below for the maximum allowable income to qualify for Medicaid coverage in the state of New York depending on your demographics, and family size.

The allowed income levels above are expanded for each child and pregnant woman in the family. See table below for figures.

Some states allow for a special income group that allows people to earn a higher income and still qualify for Medicaid coverage if they require nursing home services for at least 30 consecutive days. New York is one of ten states that do not allow for this expanded limit. The state also does not acknowledge the use of a Miller trust because it allows for the medically needy exception.

Medically Needy

For those that have a higher income than listed in the tables above, you may still qualify for Medicaid by becoming medically needy. After meeting the general requirements, you will have to “spend down” your income to reach the limits specified. This occurs by subtracting medical expenses from your income. Any expenses your state considers to be medical or remedial care, such as doctor visits and prescription drugs will count towards this process. An upside is that you do not have to actually pay for an expense you claim. It is enough to have the obligation to pay the expense for the amount to count. Please see data below for the income and asset limits for your individual circumstances.

New York Medically Needy Data Limits

  • Income Limit (Monthly)
    • Single: $825
    • Couple: $1,209
  • Asset Limits
    • Single: $14,850
    • Couple: $21,750
  • Budget Period for Spend-Down Computation: 6 months

So, if your monthly income were $1,200, as a single person you would need to incur $375 of medical expenses to qualify for Medicaid in New York. Please note that the program will not cover the expenses used to spend down your income. Any expenses for services incurred after accounting for the spend down amount will be eligible for coverage by Medicaid. 

New York uses a 6-month base period to calculate your spend down. Using the income figure of $1,200 above, you would need to incur $2,250 of medical expenses in this period to become medically needy. Remember that while you do not have to pay for the expense within this timeframe, you must have been given the obligation to pay for it. Simply booking an appointment within the timeframe would not count towards your total. Once you have reached your required spend down amount, you will receive Medicaid for the rest of the period. 

For example, if the 6-month period starts on May 1, and you incur $2,250 in medical expenses by July 20, you would receive Medicaid for the remainder of July through the end of October. However, none of your May 1-July 20 expenses will be covered. Then in November, a new 6-month base period will begin, and the process will repeat itself.

A few states including New York also allow for you to pay-in to meet your spend down limit. With a spend down amount of $2,250, after incurring $1,800 in medical expenses you could pay the state $450 to make up the rest of the balance to qualify as medically needy. Whether this will be a worthwhile option for you will depend on your circumstances. 

Which Assets are used for Calculations?

The following types of assets will be used to assess your Medicaid eligibility:

  • Checking and savings accounts
  • Stocks and bonds
  • Certificates of deposit
  • Real property other than your primary residence
  • Additional motor vehicles if you have more than one

You do not have to worry about these types of assets in your calculation:

  • Your primary residence
  • Personal property and household belongings
  • One motor vehicle
  • Life insurance with a face value under $1,500
  • Up to $1,500 in funds set aside for burial
  • Certain burial arrangements such as pre-need burial agreements
  • Assets held in specific kinds of trusts

Regarding your primary residence, as mentioned above it is not counted as one of your assets, but there is an important caveat to this. Your equity interest in the property cannot exceed a certain level, and this amount is $828,000 in New York. Any outstanding mortgage still on the property does not count towards this total. For example, a $100,000 mortgage on a property valued at $928,000 would still qualify you for Medicaid because your equity interest would only be $828,000. Another important note is that if you are a joint owner of the property with your spouse or someone else, then your equity interest is only half of the total equity value of the home. 

Unlike the equity of a home, some of your joint assets may be deemed to be yours in their full value. For example, a savings or checking account that you own with another person would be considered entirely yours for calculations due to your ability to withdraw all of the funds of the account. There are exceptions for married couples if one spouse lives in an institution, and the other does not. In these cases, the spouse living in the community can keep more of the couple’s assets so that they do not become impoverished while trying to maintain a reasonable standard of living. In 2016, such a spouse is allowed to keep up to half of the joint assets to a maximum of $119,220. Additionally, up to $2,898 of the institutionalized spouse’s income per month can be protected, depending on the income of the spouse living in the community.

After meeting the general and financial requirements, you will be assessed by a medical specialist to determine if you require long-term care assistance. Your performance on the ADLs previously mentioned (bathing, dressing, etc.) will establish your eligibility.