For many New Yorkers seeking Medicaid-funded long-term home care, Medicaid eligibility is an important first step.

Medicare alone generally does not provide ongoing custodial home care services. Medicaid may provide home- and community-based long-term services and supports for people who meet the applicable eligibility requirements.

Apply for Medicaid
If you need home care, you should apply for Medicaid at your local Department of Social Services (Human Resources Administration in New York City). You can go to a Medicaid office or apply online through Access HRA.

Complete the required state assessment
New York uses an assessment process called the New York Independent Assessor Program (NYIAP) to determine whether an individual meets the requirements for community-based long-term care. This assessment will determine whether you are eligible for services. It’s very important to explain all of your needs to the assessor and explain what tasks you can’t complete on your own. If you are determined not to be eligible for services, there will be information on the notice about how to request a Fair Hearing. You can reach NYIAP at 855-222-8350.

Enroll in an MLTC plan and complete a plan assessment
Most people who are determined eligible for home care will be required to enroll in a Managed Long Term Care Plan to receive home care services. If you are determined eligible for home care services, you will receive information about how to choose a plan and enroll. The plan will conduct an assessment before enrollment and create a plan of care (including how many hours of home care you will receive per week). You can be assessed by multiple plans but you cannot challenge a recommended plan of care before you are enrolled in a plan.

Receive a Plan of Care
Your approved plan should identify the services authorized for you, including the type and amount of home care and when your needs will be reassessed.

New York’s MLTC program can provide services including personal care, home health aide services, nursing, therapies, and Consumer Directed Personal Assistance Services.

Important Change
Since September 1, 2025, New York has additional “Minimum Needs Requirements” for many people seeking Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS). Generally, an individual must need at least limited assistance with physical maneuvering with more than two Activities of Daily Living (ADLs), with different rules for people with Alzheimer’s disease or dementia. Some people who were already receiving services or continuously enrolled before September 1, 2025 may be covered under prior criteria. These changes have made it more difficult to be determined eligible for home care. This is why it is very important to make sure you express all of your needs and limitations during an assessment.

If your health or circumstances change and you believe you need additional home-care hours:

Ask your care manager
Tell your MLTC plan that you need a reassessment or an increase in services.

Put your request in writing
Explain specifically what additional assistance you need and why.

Get medical documentation
Ask your doctor, nurse, therapist, hospital, or other appropriate health-care professional to document your current limitations and the assistance you require.

Be specific
Instead of simply saying:

“I need more hours.”

Explain:

• What activities can you no longer perform independently?
• What assistance do you require?
• How often do you require assistance?
• What has changed since your previous assessment?
• What happens when assistance is unavailable?
• Why are the currently authorized hours insufficient?

Focus on your daily care needs
Activities of Daily Living (ADLs) can include activities such as:

• Bathing
• Dressing
• Toileting
• Transferring
• Eating/Feeding
• Mobility

New York’s assessment guidance addresses ADLs and instrumental activities of daily living (IADLs), including bathing, dressing, toileting, shopping, meal preparation and other activities.

Keep copies of everything you submit.

You have the right to appeal.

If your MLTC plan denies your request for additional hours, reduces your services, or takes another adverse action, you should receive a written notice explaining the decision and your appeal rights.

Read the notice carefully and look for:
Initial Adverse Determination (IAD)
and, after a plan appeal,
Final Adverse Determination (FAD).

The notice should explain how to appeal and the applicable deadlines.

Do not miss your deadline
You will first receive an Initial Adverse Determination (IAD). You must file an appeal within 60 days from the date of the IAD to file a plan appeal. However, if your plan is discontinuing or reducing services that you are already receiving, you must file an appeal within 10 days to keep the services active during the appeal.

Do not wait until the last day
Submit your appeal as soon as possible and keep proof that you submitted it.

Include supporting evidence
Your appeal can include:

• Current doctor’s letters
• Medical records
• Hospital or rehabilitation records
• Therapy records
• Caregiver or aide documentation
• A detailed description of your ADL needs
• Information showing that your circumstances have changed
• Information explaining why your current hours are not enough

The more specific your documentation, the easier it is for the reviewer to understand your actual care needs.

Ask for a fair hearing.

If your plan upholds its decision and issues a Final Adverse Determination, you may have the right to request a New York State Fair Hearing.

A Fair Hearing allows you to explain to a State Administrative Law Judge why you believe the plan’s decision was incorrect.

You can request a fair hearing:

• By telephone: 800-342-3334
• Online at the OTDA website.
• By fax: 518-473-6735

Important: Ask about “aid continuing”
If your plan is reducing, suspending, or terminating services you are already receiving—or in certain circumstances is changing long-term services for a subsequent authorization period—you may have rights to Aid Continuing, which can allow services to continue while the appeal/hearing process is pending.

Timing is critical
Current New York guidance indicates that, in circumstances where Aid Continuing applies after a Final Adverse Determination, a Fair Hearing generally must be requested within 10 days to preserve Aid Continuing.

Do not assume that you have lost your rights. Read your notice and act immediately.

You do not necessarily need an attorney to participate in a Fair Hearing. You may represent yourself or seek assistance from an attorney or advocate.

Bring Your Evidence

• Your plan’s notices
• Your appeal
• Medical records and doctor’s letters
• Documentation of your ADL needs
• Your current Plan of Care\
• A timeline of important events
• Copies of communications with your plan
• Any evidence explaining why you need additional care

Create a timeline

• Date
• What happened
• Who you contacted
• What you requested
• What the plan decided

Keep your explanation focused on your actual care needs and the services you are requesting.

Best Specific
Explain what assistance you need with your daily activities and how often you need that assistance.

New York’s Consumer Directed Personal Assistance Program (CDPAP) program allows eligible Medicaid recipients to choose and hire their own personal assistant, subject to program rules.

A personal assistant may be a friend or certain family members. The program gives eligible consumers greater control over who provides their care.

Important
CDPAP has undergone significant changes. Since April 1, 2025, Public Partnerships LLC (PPL) has served as New York’s statewide fiscal intermediary for CDPAP.

For more information on CDPAP visit the New York State Department of Health’s website.

• • New York State Fair Hearings: 800-342-3334
  • Request a Fair Hearing online
  • New York State Medicaid / Health Coverage
  • New York State Department of Health – MLTC

• Keep your paperwork.
• Know your deadlines.
• Ask for decisions in writing.
• Document your care needs.
• Appeal if you disagree.
• Ask for help when you need it.

The information in this document has been prepared by The Legal Aid Society for informational purposes only and is not legal advice. This information is not intended to create, and receipt of it does not constitute, an attorney-client relationship. You should not act upon any information without retaining professional legal counsel.