Community Medicaid Planning for Home Care
Community Medicaid helps eligible individuals pay for long-term care at home or in certain community settings. It can cover a home health aide, hands-on personal care, adult day programs, and, in some states, services in an assisted living setting. These services can help people continue living in their community while receiving assistance with daily care needs.
Our attorneys assist with Medicaid planning for home care, from reviewing eligibility and preparing the application to maintaining benefits after approval. Families usually come to us after a hospital stay, a fall, or a dementia diagnosis, when care needs exceed the support relatives can provide or Medicare coverage is insufficient. We tailor each plan to the applicable requirements in New York, New Jersey, or Connecticut.
Key Takeaways:
- Community Medicaid pays for long-term care at home, and eligibility depends on two separate reviews: an assessment of your care needs and a review of your income and assets.
- The programs are not the same across state lines. Program names, assisted living coverage, asset-transfer rules, and options for income above the eligibility limit all differ, so planning must reflect the requirements of the applicant’s state.
- We assist with planning, applications, and ongoing coverage, including appeals when benefits are reduced or denied.
How We Can Help
We guide families through eligibility planning, the application process, and ongoing coverage. Our Medicaid planning services address both financial requirements and care needs, including changes in services or living arrangements after approval.
Community Medicaid State by State
New York
In New York, community Medicaid includes home care services, often delivered through Managed Long Term Care (MLTC) plans for people with chronic illnesses or disabilities. Covered services include home care, adult day health care, nursing and therapies at home, private duty nursing, and consumer-directed personal assistance.
Through the Consumer Directed Personal Assistance Program (CDPAP), participants may hire their own personal assistant, including certain family members, but not a spouse. Married applicants may also need advice about spousal refusal planning.
The Assisted Living Program serves people medically eligible for nursing home placement in a lower-cost setting. Services require advance approval by the local district, and out-of-pocket costs vary. Our attorneys can help clarify which expenses the program covers and which remain the resident’s responsibility. A pooled income trust administered by a nonprofit may be an option for income above the eligibility limit. Initial community health assessments are conducted through the New York Independent Assessor Program.
Asset-transfer rules are a key consideration in New York Medicaid planning. A 30-month look-back for community-based long-term care was enacted in the April 2020 State budget but requires federal approval. The look-back has not yet been implemented, and home care applications are currently reviewed without a transfer penalty. The enacted look-back provision remains subject to future implementation.
New Jersey
New Jersey’s Managed Long Term Services and Supports (MLTSS) program is part of NJ FamilyCare. Managed care organizations coordinate services in settings that include private homes, assisted living facilities, group homes, and nursing homes. Benefits include care management, home and vehicle modifications, home-delivered meals, respite care, and emergency response systems.
Clinical eligibility requires hands-on help with at least three activities of daily living, or supervision with at least three such activities because of cognitive impairment. Managed care organizations conduct assessments, and the Division of Aging Services determines clinical eligibility. A resident’s contribution toward assisted living room and board may differ from the cost of covered care services. Our attorneys can help clarify these financial responsibilities.
A County Social Service Agency reviews five years of financial records when assessing an initial MLTSS application. This review applies to home-based MLTSS as well as nursing home care. A qualified income trust can address income above the eligibility limit for applicants receiving care at home, in assisted living, or in a nursing facility. Each trust requires agency approval and annual review. For married applicants, spousal protection rules allow some marital assets to be set aside for a spouse who is not applying.
Connecticut
The Connecticut Home Care Program for Elders helps older adults receive care in the community. The Department of Social Services administers the program through contracted access agencies.
The program offers two types of funding:
- Medicaid-funded services for people who receive or would qualify for Medicaid.
- State-funded services for adults age 65 and older who do not qualify for Medicaid, are at risk of entering a care facility unnecessarily, and meet statutory income and asset limits tied to federal spousal protection figures.
Services include homemaker and companion services, meals on wheels, adult day care, transportation, mental health counseling, care management, and minor home modifications.
Assisted living coverage is limited to specific settings, including state-funded congregate housing and certain pilot or demonstration programs. Participants in the state-funded portion contribute 3 percent of their cost of care, and those above 200 percent of the federal poverty level also contribute a portion of their income, known as applied income.
The Department requires a five-year review of income and assets for applicants seeking home and community-based services who have not previously received medical assistance. Excess income is handled through a spend-down of incurred medical expenses.
| Feature | New York | New Jersey | Connecticut |
|---|---|---|---|
| Program | Community Medicaid | MLTSS (NJ FamilyCare) | CT Home Care Program for Elders |
| Home care covered | Yes | Yes | Yes |
| Assisted living covered | Yes, via the Assisted Living Program | Yes, as an MLTSS setting | Limited to certain state-funded settings |
| Look-back at home | 30-month law enacted 2020, not yet implemented | Yes, five years | Yes, five years |
| Excess income | Pooled income trust | Qualified income trust | Spend-down and applied income |
| Delivery | MLTC plans | Managed care organizations | Access agencies |
What Our Service Includes
1. Eligibility analysis and planning before filing
We begin with a written review of your income, assets, available exemptions, and transfers during the applicable review period. This analysis identifies the steps needed to establish eligibility. The plan may include spending on permitted expenses, converting assets that count toward Medicaid’s limit into assets that are exempt, and reviewing how retirement accounts affect eligibility.
The timing of trust planning depends on state requirements. A Medicaid asset protection trust holds your home and investments outside your countable resources; you retain income and, if the trust provides for it, the right to live in the home, but you cannot withdraw the trust principal.
In New York, with no community look-back in operation today, a newly funded trust can support a home care application far sooner than a nursing home application, a planning consideration that may change if the look-back provision takes effect. In New Jersey and Connecticut, the five-year review also applies to home and community-based care, making advance planning especially important.
We also evaluate options for income above the eligibility limit and protections for a spouse who is not applying for benefits. The available options depend on the state and program. When care is needed urgently, we evaluate available crisis-planning options, including exempt transfers of the home, personal care agreements, and, in New York, the gifting and promissory note strategy, also known as half-a-loaf planning.
2. Preparing and managing the application
We prepare, submit, and manage your application throughout the review process. We assemble account statements for the required review period, deeds, insurance documents, and retirement records, along with supporting explanations for deposits and transfers. Thorough documentation helps address questions about whether a transfer was a gift. We respond to requests for additional information and follow up with the reviewing agency to address delays.
We help you prepare to describe your ongoing care needs accurately during the clinical assessment, including how those needs vary from day to day. We also coordinate the financial and clinical reviews to help prevent delays in enrollment.
3. After approval
Maintaining coverage requires ongoing attention after approval. We handle annual recertifications, report changes in income, resources, and living arrangements, and review approved care hours as your needs change. If you need to move to assisted living or a nursing home, we assist with the transition and review how the new setting affects financial eligibility and asset-transfer requirements.
We represent clients in appeals involving denied eligibility, reduced care hours, transfer penalties, or terminated coverage. We obtain the agency record, review the basis for its decision, and present the case through the state’s hearing process. Deadlines for these appeals are short and vary by state and notice type, so contact us promptly upon receiving a notice. Ongoing planning support, including annual trust reviews, is available through our Client Care Program.
Common Mistakes to Avoid
- Assuming every state has the same rules. A transfer of assets can affect Medicaid eligibility differently depending on the state. Get advice about the rules that apply where you are seeking care before giving away money or property.
- Giving money to family members without keeping records. Missing documentation can make it harder to explain transfers during the application review.
- Paying a family caregiver without a written agreement. Document the care arrangement and payments so they can be explained if the agency questions them.
- Understating care needs during the assessment. Describe the help needed with everyday activities, including difficulties that arise on more challenging days.
- Setting up an income trust without confirming the requirements. Before establishing or funding a trust, confirm whether it is appropriate and what approval and funding rules apply.
When Care at Home Is No Longer Enough
Community Medicaid can help pay for care at home, but the available services may not meet every person’s needs. If staying at home is no longer safe, our attorneys can help you understand Medicaid eligibility for nursing home care and plan for the transition.
Schedule a Community Medicaid Consultation
As care needs increase, early planning can help you understand your options and prepare for the cost of ongoing support. Bring a list of accounts, the deed to the home, any existing trust or power of attorney, and a description of the assistance you need during a typical day. Our attorneys practice in New York, New Jersey, and Connecticut.
This page is provided for general informational purposes only and does not constitute legal advice. Laws differ by state and change over time. For advice about your situation, consult a qualified attorney.
Frequently Asked Questions
What is community Medicaid?
Community Medicaid is Medicaid coverage for long-term care delivered where you live rather than in a nursing home. It can pay for a home health aide, hands-on personal care, adult day programs, and, in some states, services in an assisted living setting. States use different names for the program and cover different services.
How is community Medicaid different from nursing home Medicaid?
Home care and nursing home care have different Medicaid eligibility requirements. The level-of-care standard, the way transfers are reviewed, and the treatment of a spouse’s income and resources can all differ between the home setting and the institutional setting. A change in care setting may therefore require a new eligibility review and adjustments to your plan.
Does Medicare pay for home care?
Medicare pays for short, skilled episodes of home health care, such as nursing or therapy after a hospital stay. It does not pay for ongoing custodial help with bathing, dressing, and similar daily activities. That long-term help is what community Medicaid is designed to cover.
Can a family member be paid to provide the care?
In some states, yes. Consumer-directed programs allow the person receiving care to hire and direct a caregiver, and in some cases a family member or friend can be paid through the program. Separately, paying a relative privately generally requires a written personal care agreement, because an undocumented payment can be treated as a gift.
Is there a look-back period for home care Medicaid?
It depends on the state. Some states apply the same transfer review to home and community-based services that they apply to nursing home care, and others do not currently review transfers for community services. Confirm your state’s current rules before transferring money or property.
What happens if my income is too high?
Income above the program limit does not automatically disqualify you. Depending on your state, age, and disability status, the surplus may be spent down on medical costs each month, placed in a qualified income trust, or deposited into a pooled income trust administered by a nonprofit. These arrangements usually require agency approval and must be funded correctly each month.
Will Medicaid pay for assisted living?
Coverage depends on the state and program. Medicaid may pay for care services in an assisted living facility, while room and board may remain the resident’s responsibility. Confirm what your state’s program pays for before committing to a particular residence.
Can I qualify for home care Medicaid if I own my home?
Often yes. A primary residence is commonly exempt from countable resources, subject to equity limits and other conditions that vary by state. An attorney should also review how Medicaid estate recovery rules could affect the home and what planning options are available.
Does a Medicaid asset protection trust help with home care?
It can, but the timing depends on your state. Where a state does not apply a transfer look-back to community services, a newly funded trust may support a home care application much sooner than it would support a nursing home application. Where the state does review transfers for home care, funding the trust starts a waiting period that must run first.
How do I start a community Medicaid application?
The application process includes an assessment of your care needs and a financial eligibility review by the responsible agency. Gathering account statements and other required records early can help avoid delays caused by missing documentation.
