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Selfhelp - The Source for Independent Living

Legal Bulletin

The new year has just started and already there is lots of news for 2013:

A.  New 2013 Medicaid Income and Asset Limits

D.   EPIC is back for 2013!

E.   Medicaid Home Care Update

  1. NYC Home Care Services Program -  New location for main administrative office, including address for mailing new Medicaid applications citywide
  2. Managed Long Term Care --  January 2013 Expansion of Mandatory MLTC to Nassau, Suffolk and Westchester counties AND
    • Mandatory enrollment begins of long-term certified home health agency recipients, adult day care and private duty nursing services in New York City, Suffolk, Nassau & Westchester
  3. Updated information about Managed Long Term Care, including updated plan contact lists of plans for NYC and the rest of the state -- for MLTC, Medicaid Advantage Plus and PACE.   
  4. Managed Long Term Care - Know Your Appeal & Grievance Rights in Transition from Medicaid CASA/DSS personal care/home attendant/consumer-directed personal assistance program (CDPAP) services.
  5. UPDATED Tools for Selecting a Managed Long Term Care Plan

A.  New 2013 Medicaid Income and Asset Limits

The new 2013 Medicaid income and resource limits have been release in HRA's new chart posted in this article Income and Resource Limits for New York State Public Health Insurance Programs (Direct link is to this handy two-page chart)

The most commonly used limits for adults age 65+ or who are disabled or blind are in BOX 3 of the chart:

                        INCOME                                    SAVINGS

Singles              $800/mo                                  $14,400

Couples           $1,175/mo                               $21,150

Note that the Medicare Savings Program limits (Box 8 on page 2), Family Health Plus (Box 4(b) for adults without kids under age 21), and some other limits are not yet increased for 2013, because the federal government has not yet announced the Federal Poverty Levels for 2013.

B.    2013 Social Security COLA Increase Threatens Medicaid Disruption for People Using Pooled Trusts  and Others with Spend-down - Tips for Advocacy

Many NYC Medicaid recipients who had no spend-down in 2012, either because they are too poor or because they were using a pooled trust to eliminate their spend-down, have received Notices DISCONTINUING their Medicaid because they now have a spend-down as a result of the cost of living increase in their Social Security.    Selfhelp's Evelyn Frank Legal Resources Program demanded that  the State and City Medicaid programs  revoke these notices because they are illegal and will have devastating consequences.  Discontinuance of Medicaid could result in disruption of vital home care services if Managed Long Term Care plans disenroll members because their Medicaid cases have closed.    

  • Many of these individuals are enrolled in pooled trusts, and therefore had no spend-down.  Because of the COLA, they have a small spend-down because they are not yet depositing the increased income into the trust.   We told the State these individuals should have the chance first to deposit the increased income into the trust -- or simply be billed for the additional spend-down.  

NEWS FLASH -- On Friday Jan. 10th, HRA notified Selfhelp that they would revoke the notices of discontinuance sent to 13 people enrolled in pooled trusts and to 78 people  enrolled in Managed Long Term Care Plans.   They will receive new notices -- hopefully ones that meet legal mandates.   Notices outside of NYC are scheduled to be sent in late January -- we do not yet know if the State will revise its procedures for these notices as a result of our advocacy.  

ADVOCACY TIPS -  Despite the progress made on getting these notices canceled, we still recommend that you:

  • Request a Fair Hearing before the effective date of the notice, in order to protect their Medicaid. 
  • If your client uses a pooled trust,  increase the amount they put into the trust, each month beginning in January, in the same amount their income has increased.  You need to provide proof of that to the Medicaid office, and ask that they adjust the Medicaid budget accordingly.  You can use this worksheet to calculate the proper amount to contribute.
  • TIP for MLTC Applicants who have a Spend-down:  If client is applying for Managed Long Term Care and has a spend-down, make sure to ask the Medicaid program to code them with “Provisional Medicaid” – this way the MLTC plan will not DENY enrollment because they have not yet met the spend-down.  See  Medicaid Alert dated July 12, 2012.

C.   Medicaid Coverage for Compression Stockings and Orthopedic Footwear

One of the budget cuts last year was the elimination of Medicaid payment for orthopedic footwear and compression stockings.   A lawsuit was brought and on January 7, 2013, Judge Charles J. Siragusa signed an order certifying a class in Davis et al v. Shah (Case number: 12-CV-6134-CJS)

Empire Justice Center and the National Health Law Program are representing the plaintiffs in the lawsuit, and won a preliminary injunction for individual plaintiffs.     With the class certification order,  Medicaid recipients who need these services should be able to gain access as well.

If you know of Medicaid recipients who have been unable to get Medicaid coverage for these services, please contact the Health Law Unit at the Empire Justice Center at
1-800-724-0490.

The class certification order also requires the state to inform Medicaid providers and suppliers of the availability of coverage for compression stockings and orthopedic footwear.  Here’s the link to the posting on the DOH website:  http://www.health.ny.gov/health_care/medicaid/program/update/2013/noticejan2013.htm.

The Empire Justice Center has posted the notice on its website here. 

D.   EPIC is back for 2013!

EPIC is back to being the terrific program it used to be before devastating cuts in 2012.  Beginning this month, EPIC again subsidizes the Part D drug costs for seniors age 65+.  If your clients age 65+ are not in EPIC, or dropped it in 2012 because it really wasn’t much help, reach out and help them apply again.  For more info see  What you need to know about EPIC - New York's prescription drug program for seniors - 2013 Changes . Also see this update on the EPIC website.

Anyone in the EPIC FEE plan has received a bill to pay the 2013 Fee.  If they have not paid the fee, EPIC will be cut off on February 11, 2013.  Final bills are being mailed this week. 

E.   Medicaid Home Care Updates

1.  NYC Home Care Services Program -  New location for main administrative office, including address for mailing new Medicaid applications citywide

The HRA Medicaid Home Care Services Program's main office moves on January 14th from 109 E. 16t St. in Manhattan, to Brooklyn.  This includes the Medicaid unit, which is where Medicaid applications may still be mailed by people seeking home care, even though "dual eligibles" (people with Medicare) must enroll in a managed long term care plan once Medicaid is approved.  They Home Care/CASA program will no longer process M11qs or authorize home care for dual eligibles.  To see the updated Home Care Services Program/CASA Contact List, and for more information on MLTC applications see this article

Mandatory enrollment begins of long-term certified home health agency recipients, adult day care and private duty nursing services in New York City, Suffolk, Nassau & Westchester

3.     Updated information about Managed Long Term Care, including updated plan contact lists of plans for NYC and the rest of the state -- for MLTC, Medicaid Advantage Plus and PACE.  

4.     Know Your Appeal & Grievance Rights in Transition to MLTC from Medicaid CASA/DSS personal care/home attendant/consumer-directed personal assistance program (CDPAP) services.

5.     UPDATED Tools for Selecting a Managed Long Term Care Plan

F.     Gov. Cuomo has once again proposed to eliminate spousal refusal in the proposed budget issued this week.     

Spousal refusal has long enabled a couple to get the Medicaid services needed for one spouse who has a disability or chronic illness, while still retaining enough income and assets to live on.   Without spousal refusal, a "well" spouse would have to either (1)  get a divorce or  (2)  place the "sick" spouse in a nursing home -- only by doing that would she be allowed to retain enough income and assets to live on.  Otherwise, the couple would have to live at the Medicaid level-- which is below the Federal Poverty Level -- and could never meet basic living expenses.   

The Governor did propose to help some married couples by giving "spousal impoverishment" protections to couples where one spouse is in a managed long term care plan.  These are the same protections now available in the Lombardi Long Term Home Health Care Program, and -- if approved by the federal government --would ensure continuation of these protections if and when  Lombardi program participants are required to join managed long term care plans.   Even if approved by the federal government, however, these "spousal impoverishment" protections would not undo the harm of eliminating spousal refusal. 

  • First, not all married persons who need Medicaid need it for managed long term care services -- they may need medical care for other chronic health conditions.   They would now be denied Medicaid because a spouse needs their income to pay basic living expenses. 
  • Second, the proposed change would also eliminate "parental refusal," depended on by families with children with disabilities or chronic illness need Medicaid.   Many of these families need every dollar of their income and savings to pay for their everyday expenses and the needs of other children -- and could never afford the cost of medical care for a chronically ill child. 
  • Third, the spousal impoverishment protections -- even if enacted -- do not help many other couples who would be hurt by eliminating spousal refusal.  We are still analyzing the gaps in this coverage.   
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