Community Medicaid in New York: Act Now to Avoid Losing Coverage

Fact: Community Medicaid in New York is changing. It’s critical that seniors take action to avoid losing healthcare coverage.

Currently, federal COVID public health emergency (PHE) rules require states to adhere to the continuous enrollment requirement in the 2020 Families First Coronavirus Response Act (FFCRA). This means that states must provide continuous coverage for Medicaid recipients until the federal PHE ends — in exchange for enhanced federal matching of Medicaid dollars.

When the PHE terminates, states like New York will revert to conducting periodic eligibility checks or redeterminations of eligibility. It’s estimated that between 5.3 million and 14.2 million people could lose Medicaid coverage during the 12-month unwinding period after the PHE ends. Already, 25 governors have urged the White House to end the PHE in 2023, citing record enrollments that have led to state Medicaid funding challenges.

Preparation is key to self-preservation and autonomy.

A Tale of Two Medicaid Applicants

A retired nurse, Janet enjoys backyard barbecues in the summer and museum outings in the winter. Well-read and outgoing, she’s usually the life of the party at senior gatherings.

At 75, Janet is fiercely independent. She still lives in the split-ranch home she once shared with her husband, Gary, who died from colon cancer last year.

Janet has arthritis and is grateful that Medicare pays for medically necessary outpatient physical therapy and prescription NSAIDs (nonsteroidal anti-inflammatory drugs).

However, she isn’t currently a Medicaid recipient. Her children Jeremy and Nancy are concerned that their mother may need assistance with activities of daily living as her disease progresses.

Private-pay assisted living and nursing home facilities command premium prices in New York. In Long Island, it would cost upwards of $168,144 annually for nursing home care and up to $9,125 monthly for assisted living.

Jeremy and Nancy have decided that Community Medicaid is a good option, but Janet is resistant to the idea.

Two doors down, Janet’s neighbor 45-year-old Todd has been enrolled in Medicaid since 2019. A former oil rig engineer, Todd became a paraplegic after a disastrous workplace injury involving heavy machinery.

Each day of the week, personal care aides help Todd with activities of daily living (ADL) from 2:00 PM to 8:00 PM. In 2022, Todd won an $18.1 million dollar settlement for damages sustained.

Both Janet and Todd would be shocked to know that new rules could soon end safety-net provisions for their care.

New Medicaid Income and Asset Limits Could Jeopardize Eligibility

New York’s Community non-MAGI (modified adjusted gross income) Medicaid program provides community-based long-term care (CBLTC) to elderly, blind, and disabled persons.

On January 1, 2023, the Medically Needy Income Level (MNIL) increased from 100% to 138% of the Federal Poverty Line (FPL), per GIS 22 MA/11. For SSI-related individuals:

  • Singles will see an income limit increase from $934 to $1,563/mo
  • Couples will see an income limit increase from $1,367 to $2,106/mo
  • Singles will see resource limits increases from $16,800 to $28,133 and couples $24,600 to $37,902

Recipients of non-MAGI Medicaid can request a budget review to see if they can contribute less of their income for coverage in 2023.

For non-MAGI enrollees with excess income, a consultation with an experienced elder law attorney is critically important.

The New NYIA Provision Could Delay Care for Seniors

Individuals who apply for Community Medicaid must now get an assessment from an NYIA (New York Independent Assessor) rather than their own personal physician.

Consumer advocates such as Medicaid Matters NY have sounded the alarm that the new NYIA requirement could delay critical care to vulnerable citizens.

Fortunately, applicants can now choose a trusted representative or attorney to act on their behalf in all matters pertaining to New York Medicaid Choice (NYMC) and the New York Independent Assessor (NYIA) program.

New Medicaid Lookback Rules Could Lead to Loss of Coverage — But There’s Hope

In addition to the new income and asset limits, there will be a penalty for individuals who transfer assets during the lookback period. The transfer penalty is a period of ineligibility for Medicaid benefits based on the amounts transferred.

In 2020, New York’s Medicaid Redesign Team (MRT) II proposed a 30-month lookback and transfer penalty for community based home care applications, similar to those that now exist for Medicaid nursing home applications.

This proposal was approved as part of the 2021 New York State budget. However, due to the PHE and other COVID legislation, the lookback has now been tabled until April 1, 2024.

The American Rescue Plan Act (ARPA) also has a Maintenance of Effort requirement which prohibits states from restricting Community Homecare eligibility until March 31, 2025 or until ARPA funds are spent.

Penalty Transfer Rates: Long Island & New York City Top the List

During the look-back period, penalties assessed will be based on uncompensated asset transfers. As of January 2023, the transfer rates per GIS 22 MA/12 are as follows:

New York City     $14,142

Bronx                   Staten Island

Queens                Manhattan


Northeastern       $12,744

Albany       Fulton             Saratoga

Clinton       Greene           Schenectady

Columbia   Hamilton         Schoharie

Delaware   Montgomery   Warren

Essex        Otsego            Washington

Franklin     Rensselaer

Long Island           $14,136



Western              $12,130

Allegany            Erie             Orleans

Cattaraugus      Genesee     Wyoming

Chautauqua      Niagara

Northern Metropolitan    $13,906

Dutchess             Orange              Ulster

Sullivan               Westchester

Rockland             Putnam

Central    $11,726

Broome       Jefferson      Oswego

Cayuga        Lewis           St. Lawrence

Chenango    Madison      Tioga

Cortland       Oneida        Tompkins

Herkimer      Onondaga

Rochester     $13,421

Chemung                Seneca

Livingston               Steuben

Monroe                   Wayne

Ontario                   Yates



Both Janet and Todd live on Long Island. Let’s say Janet decides to apply for Community Medicaid in 2027. She transfers $500,000 to her grandchildren to qualify for care. If the new lookback rules are implemented in 2024, she’ll be denied Community Medicaid benefits for 35 months.

500,000/14,136 = 35.37

Essentially, for every $14,136 gifted, Long Island Medicaid applicants will be denied homecare services for one month.

Presently, however, there’s NO look-back or penalty period for Medicaid Home Care benefits.

Thus, Medicaid applicants must act immediately. Janet should file now and request CBLTC services on the Supplement A DOH 5178A form to be “grandfathered” in with no lookback penalties later:

…individuals who apply for Medicaid coverage of CBLTC before the implementation date will not be subject to the 30-month lookback, including those individuals who file a pre-implementation date application for Medicaid coverage of CBLTC but who are not yet receiving CBLTC services under that application on the implementation date (New York MRT Waiver Request).

Once these rules change, Janet may be left without provisions for her future care.

Those like Todd, who are already Medicaid recipients, won’t be subject to lookback and transfer penalties when they are implemented in 2024:

Individuals currently… receiving or applying for CBLTC services on or before the implementation date will be grandfathered in and not subject to the 30-month lookback (New York MRT Waiver Request).

However, failure to meet the new income and asset thresholds will mean Todd may still lose his Medicaid Community coverage.

Sheryll Law: Protecting Healthcare Coverage for Seniors With Medicaid Planning

To avoid losing coverage, planning is critical.

Contact our experienced elder law attorneys at (631) 506-8440 or fill out a short form on our website. We’ll present favorable options for asset and income protection before the look-back period is implemented.

Sheryll Law is one of the top Medicaid law firms in New York. We are an award-winning member of the National Academy of Elder Law Attorneys with extensive experience in long-term care planning.

Our Medicaid lawyers are on standby. Don’t get trapped by asset transfers and income limit rules after submitting a Medicaid application. A comprehensive Medicaid planning strategy can protect a lifetime of hard-earned assets.

Copyright © 2023. Sheryll Law, P.C. All rights reserved.

The information in this blog post (“post”) is provided for general informational purposes only and may not reflect the current law in your jurisdiction. No information in this post should be construed as legal advice from the individual author or the law firm, nor is it intended to be a substitute for legal counsel on any subject matter. No reader of this post should act or refrain from acting based on any information included in or accessible through this post without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer licensed in the recipient’s state, country, or other appropriate licensing jurisdiction.

Sheryll Law, P.C.
633 East Main Street, Suite 2
Riverhead, New York 11901
(631) 506-8440