Updates on the 2020 Medicaid Changes Enacted in the 2020 NYS Budget by the Medicaid Redesign Team II (MRT-2)
After being on pause due to COVID relief law, changes made by the MRT-2 for the 2020 NYS Budget will take effect starting September 1, 2025. These changes impose three new “ADL thresholds” that New York Independent Assessor Program (“NYIAP”) will consider in assessing enrollees in NYS Medicaid Personal Care, CDPAP, and MLTC plans.
What is the New York Independent Assessor Program (NYIAP)?
NYIAP was established in NYS after the state in 2020. The goal of NYIAP is to perform assessments for individuals applying for NYS Medicaid plans such as the Consumer Directed Personal Assistance Program (CDPAP) or Personal Care Services (PCS), and Managed Long-Term Care.
What are Activities of Daily Living (ADL)?
According to the National Institute of Health, ADLs are: “These activities include personal care tasks such as eating, dressing, bathing, toileting, managing continence, and transferring (moving from one position to another).”
How are Activities of Daily Living (ADLs) determined by the New York Independent Assessors Program (NYIAP)?
ADLs are scored by nurses at NYIAP. There are seven degrees of assistance under NYIAP:
Independent
Independent, set up only– Article or device placed within reach, no physical assistance or supervision in any episode
Supervisory Assistance: oversight
Limited assistance: guided maneuvering of limbs
Extensive assistance: weight-bearing support by one where the person still performs 50% or more of the subtasks
Maximal assistance: weight-bearing support by two or more helpers or weight-bearing support for more than 50% of subtasks
Total dependence: full performance by others during all episodes
What is the rule currently?
Before the MRT-2 changes, for CDPAP/PCS, NYIAP requires that members need assistance with one or more personal care services, home health aide services, or skilled nursing tasks.
What are the new minimum ADL requirements?
After September 1, 2025, enrollees in Personal Care and CDPAP services will be required to have “limited assistance with physical maneuvering” for THREE Activities of Daily Living or supervisory assistance with TWO ADLs for people diagnosed with Alzheimer’s disease or dementia. Additionally, new housekeeping services for personal care at home will not be available for new applicants.
In other words, the new rules would require three ADLs with these scores, unless the person has dementia, in which case, a person with dementia or Alzheimer’s would need supervision assistance or a higher level of assistance with two ADLs.
Example 1: Suppose person X requires limited assistance with bathing and dressing, and extensive assistance with toileting. Furthermore, person X does not have dementia or Alzheimer’s disease. Person X in this example would qualify under the new three minimum ADL requirements.
Example 2: Suppose person Y has dementia and requires supervisory assistance with eating and limited assistance with dressing, then person Y would qualify under the new three minimum ADL requirements.
Example 3: Suppose person Z requires limited assistance with eating because of difficulties swallowing food but is independent in all other Activities of Daily Living. Furthermore, person Z does not have an Alzheimer's diagnosis or dementia. Person Z would therefore not qualify because they have not met the new three minimum ADL requirements.
Do I need to be enrolled in CDPAP, Personal Care, or an MLTC plan by September 1, 2025?
No, you do not have to be enrolled in any of the above or local DSS/HRA by September 1, 2025, BUT you must be assessed by NYIAP between September 1, 2024, and September 1, 2025, and be enrolled in one of the above programs or authorized by local DSS/HRA within one year of being assessed.
Being grandfathered in
To have legacy status/to be grandfathered in, meaning, to not be subject to the new changes in the law, you must either:
Have been enrolled in an MLTC plan as of August 1, 2025, or authorized to be assessed and authorized by the local DSS for a program, or
Have been assessed by NYIA on or after September 1, 2024, and before September 1, 2025, but not yet enrolled in MLTC or not yet authorized by the local DSS for a program before September 1, 2025, as long as you enroll in MLTC or are authorized by DSS for PCS/CDPAP within 1 year of the NYIAP assessment.
Can you lose legacy status?
If you are in an MLTC plan, then there cannot be a break in your enrollment or a gap. Having a break in or a gap in enrollment will mean you will be subject to the new ADL thresholds.
To request a NYIAP assessment, call 1-855-222-8350. NYIAP is available Monday through Friday, 8:30 a.m. to 8:00 p.m.
For all Independent Assessor problems, please contact the State NYIA at 518-474-5888 or independent.assessor@health.ny.gov
DISCLAIMER: This blog post does not establish an attorney-client relationship and does not constitute legal advice. Every case is complex and different, and the information herein is subject to change at any time. Please contact us at 716-853-3087 to talk about your specific circumstances and see if we can assist you.