Protecting Your
Property and Your
Family
Property and Your
Family
Member Of:
New York Medicaid Lawyer
Paying for medical care or nursing home services can be overwhelming, especially when you are trying to protect your savings and provide for your family. Many people turn to Medicaid during difficult times and are unsure where to begin. New York Medicaid is a joint federal and state program that provides health coverage to people with limited income and resources. It pays for medical care, long term care, home care, nursing home care, and other services for eligible residents. Medicaid rules are complex and change often. Federal statutes, New York statutes, regulations, and court decisions all affect who qualifies and what services are covered. If you or a family member is concerned about eligibility, asset protection, or long term care costs, consulting an experienced New York Medicaid lawyer can help you understand your rights and obligations under current law.
Medicaid is governed at the federal level by Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. In New York, Medicaid is authorized under N.Y. Social Services Law § 363 et seq., and administered by the New York State Department of Health and local social services districts. The program operates under both federal regulations found in 42 C.F.R. Parts 430 through 456 and state regulations found in 18 N.Y.C.R.R. Parts 358 and 360.
What Is Medicaid in New York and How Does It Work?
Medicaid in New York is a public health insurance program that provides medical coverage for eligible residents with limited income and resources. It is funded jointly by the federal government and the State of New York. While federal law sets overall requirements, New York operates its own program within those rules.
The legal authority for Medicaid comes from Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. Under 42 U.S.C. § 1396a, each state must submit a state plan explaining how it will administer Medicaid. In New York, the program is implemented under N.Y. Social Services Law § 363 et seq., and administered by the New York State Department of Health together with local departments of social services and, in New York City, the Human Resources Administration.
Medicaid in New York is not a single type of coverage. It includes several categories based on a person’s age, disability status, living situation, and level of care needed. These include:
- Community Medicaid for individuals living at home
- Institutional Medicaid for those residing in nursing homes
- Managed long term care for people who require home care services
- Medicaid for families and children
- Medicaid for individuals who are aged, blind, or disabled
Eligibility rules and covered services vary depending on the category under which a person applies. Financial standards, medical necessity requirements, and documentation rules may differ from one category to another. Because these rules involve detailed statutory and regulatory analysis, many applicants choose to consult an experienced New York Medicaid lawyer before applying or challenging an agency decision.
What Are the Requirements to Qualify for Medicaid?
Eligibility for Medicaid in New York depends on income, resources, age, disability status, and level of care needs. The specific rules vary depending on whether the applicant is seeking community coverage or institutional coverage.
Under N.Y. Social Services Law § 366, eligibility is based on financial need. Federal law at 42 U.S.C. § 1396a(a)(10) requires states to provide coverage to certain mandatory categories of individuals and allows coverage for optional groups.
Income requirements are set annually and vary based on household size and category. For individuals who are aged, blind, or disabled, income limits are tied to the federal poverty level and Supplemental Security Income standards. Resource limits apply to countable assets such as bank accounts, investments, and certain property.
Some assets are exempt. In general, the following are not counted for eligibility purposes:
- A primary residence, subject to equity limits under 42 U.S.C. § 1396p(f)
- One vehicle
- Personal belongings and household goods
- Certain burial funds
For nursing home Medicaid, there is a five year lookback period for transfers of assets. Under 42 U.S.C. § 1396p(c) and N.Y. Social Services Law § 366(5)(e), if an applicant transfers assets for less than fair market value within five years before applying, a penalty period may be imposed during which Medicaid will not pay for nursing home care.
Spousal impoverishment rules also apply when one spouse is institutionalized and the other remains in the community. Federal law at 42 U.S.C. § 1396r-5 protects a portion of the couple’s income and resources for the community spouse. New York implements these protections through state regulations in 18 N.Y.C.R.R. § 360-4.10.
Given the complexity of income rules, resource calculations, transfer penalties, and spousal protections, consulting an experienced New York Medicaid lawyer can help ensure that applications are prepared correctly and that rights are protected.
What Does Medicaid Cover?
Medicaid in New York covers a broad range of medical and long term care services. Federal law requires certain mandatory services under 42 U.S.C. § 1396d(a), and allows states to provide additional optional services.
In New York, Medicaid typically covers:
- Hospital care
- Physician services
- Laboratory and diagnostic services
- Prescription drugs
- Nursing home care
- Home health services
- Personal care services
- Managed long term care
- Mental health services
- Substance use treatment
Nursing home coverage is governed by federal standards under 42 U.S.C. § 1396r, which sets requirements for nursing facility services and resident protections. Home and community based services are often provided under waiver programs authorized by 42 U.S.C. § 1396n(c).
New York also operates managed care programs under federal waivers. These programs require eligible beneficiaries to enroll in managed care plans that coordinate services.
Disputes over coverage and services sometimes result in litigation. Courts have reviewed whether state Medicaid policies and plan amendments comply with federal statutory requirements. For example, in Davis v. Shah, 821 F.3d 231 (2d Cir. 2016), the Second Circuit reviewed New York’s 2011 Medicaid plan amendments that restricted coverage of orthopedic footwear and compression stockings, addressing whether certain provisions of the Medicaid Act could be privately enforced and analyzing related claims under the Americans with Disabilities Act and the Rehabilitation Act.
Note that Medicaid does not cover every type of service. Certain elective procedures, private duty nursing beyond approved limits, and some non-medical services may not be covered. Coverage decisions are subject to administrative review and appeal.
What Is Medicaid Planning?
Medicaid planning refers to the process of arranging finances and assets to qualify for Medicaid benefits while complying with state and federal law. It often involves long term care planning for seniors who may need nursing home care or extensive home care.
Planning strategies may include:
- Reviewing countable and exempt assets
- Structuring income to meet eligibility limits
- Considering pooled income trusts under N.Y. Social Services Law § 366(2)(b)(2)(iii)
- Evaluating permissible transfers
- Creating irrevocable trusts that comply with 42 U.S.C. § 1396p(d)
Federal law places strict limits on trusts and transfers. Under 42 U.S.C. § 1396p(d), certain trusts are counted as available resources depending on their structure and terms. Improper transfers or non-compliant trusts can result in penalties or denial of benefits.
New York courts have upheld transfer penalty determinations where applicants did not satisfy statutory exceptions to the lookback rule. In Matter of Williams v. Weiner, 42 A.D.3d 901 (4th Dep’t 2007), the Appellate Division affirmed the imposition of a Medicaid ineligibility period after concluding that an annuity transaction during the lookback period was not a transfer for the sole benefit of the applicant’s spouse within the meaning of Social Services Law § 366(5)(d)(3)(ii).
Because planning involves detailed review of statutes, regulations, and agency guidance, consulting an experienced New York Medicaid lawyer can help ensure that planning steps are lawful and aligned with long term goals.
How Do I Apply for Medicaid?
Applications for Medicaid in New York are filed through local departments of social services or the Human Resources Administration in New York City. Applications may also be submitted through the New York State of Health marketplace for certain categories.
The application process requires:
- Completion of the appropriate Medicaid application form
- Submission of proof of identity and residency
- Documentation of income
- Documentation of assets
- Proof of medical need for certain categories
Regulations governing the application process are found in 18 N.Y.C.R.R. § 360-2 and related provisions. Applicants must provide complete and accurate information. The agency reviews financial records and may request additional documentation.
Once an application is submitted, the agency must issue a written notice of approval or denial. Federal law requires that notices include reasons for the decision and information about appeal rights. See 42 U.S.C. § 1396a(a)(3).
If approved, coverage may be retroactive for up to three months prior to the application date if the applicant was eligible during that period.
If denied, the notice must state the reasons and inform the applicant of the right to request a fair hearing. Mistakes in documentation or misunderstandings about eligibility rules can lead to denials that may be corrected on appeal.
Working with an experienced New York Medicaid lawyer during the application process can reduce the risk of errors and improve the likelihood of approval.
What Is the Medicaid Appeals Process?
Applicants and recipients have the right to challenge adverse decisions through a fair hearing process. The right to a hearing is established under 42 U.S.C. § 1396a(a)(3) and implemented in New York under 18 N.Y.C.R.R. Part 358.
A fair hearing may be requested if:
- An application is denied
- Services are reduced or discontinued
- A transfer penalty is imposed
- A claim for recovery is made
Requests for a fair hearing must be made within specified time limits, usually within 60 days of the notice. Hearings are conducted before an administrative law judge through the Office of Temporary and Disability Assistance.
At the hearing, the applicant or recipient may present evidence, call witnesses, and be represented by counsel. The agency must present its basis for the decision. After the hearing, a written decision is issued.
If the fair hearing decision is unfavorable, the applicant may seek judicial review through an Article 78 proceeding under N.Y. C.P.L.R. § 7801 et seq. Courts review whether the agency decision was arbitrary, capricious, or affected by error of law.
New York courts have addressed Medicaid appeals in numerous cases, including Matter of Schachner v. Perales, 85 N.Y.2d 316 (1995), which reviewed administrative determinations in the Medicaid context.
Given the procedural requirements and evidentiary rules involved, contacting an experienced New York Medicaid lawyer can help protect your rights during a fair hearing and any subsequent court review.
Frequently Asked Questions (FAQs)
Q. Can Medicaid Take My Home?
A. Under 42 U.S.C. § 1396p(b) and N.Y. Social Services Law § 369, New York may seek estate recovery after a Medicaid recipient dies. Estate recovery generally applies to benefits paid for nursing home care, home and community based services, and related hospital and prescription services.
During the recipient’s lifetime, the primary residence is often treated as an exempt asset for eligibility purposes, subject to an equity limit under 42 U.S.C. § 1396p(f). However, if the recipient permanently enters a nursing home and there is no spouse or certain protected relatives living in the home, estate recovery may later apply. Proper planning may reduce the risk of recovery.
Q. What Is a Special Needs Trust?
A. A special needs trust is a trust created for a person with a disability to hold assets without disqualifying that person from Medicaid. Federal law governing these trusts is found in 42 U.S.C. § 1396p(d)(4)(A).
This type of trust must be established for a disabled individual under age 65, and it must contain a provision requiring reimbursement to the state for Medicaid benefits paid upon the beneficiary’s death. When properly drafted and administered, assets in the trust are not counted as available resources for Medicaid eligibility.
Q. What Is a Pooled Income Trust?
A. A pooled income trust is authorized under 42 U.S.C. § 1396p(d)(4)(C). It allows individuals who have income above Medicaid limits to deposit excess income into a trust managed by a nonprofit organization.
In New York, pooled trusts are often used by individuals seeking Community Medicaid who need home care but whose monthly income exceeds the program limit. Once income is deposited into the pooled trust, it is not counted for Medicaid eligibility purposes, provided the trust complies with federal and state rules.
Funds in the trust are used to pay for approved expenses for the beneficiary. Upon the beneficiary’s death, remaining funds may either be retained by the nonprofit or used to reimburse the state for Medicaid benefits, depending on the trust terms.
Q. What Is a Medicaid Asset Protection Trust (MAPT)?
A. A Medicaid Asset Protection Trust, commonly referred to as a MAPT, is an irrevocable trust designed to hold assets so they are not counted for Medicaid eligibility after the five year lookback period has passed.
The governing federal statute is 42 U.S.C. § 1396p(d), which sets out how trusts are treated for Medicaid purposes. If a trust allows the grantor access to principal, the assets may be considered available resources. A properly structured irrevocable trust limits the grantor’s access to principal while allowing certain retained rights, such as income or limited control.
Transfers into a MAPT are subject to the five year lookback for nursing home Medicaid under 42 U.S.C. § 1396p(c) and N.Y. Social Services Law § 366(5)(e). If an applicant applies for nursing home Medicaid within five years of funding the trust, a penalty period may be imposed.
Q. What Is the Penalty for Nursing Home Care?
A. The penalty for nursing home care refers to the period during which Medicaid will not pay for institutional services due to transfers of assets for less than fair market value during the five year lookback period.
Under 42 U.S.C. § 1396p(c), the penalty period is calculated by dividing the total value of the transferred assets by the regional nursing home rate established by the state. New York implements these rules through 18 N.Y.C.R.R. § 360-4.4.
The penalty does not begin at the time of the transfer. It begins when the individual is otherwise eligible for Medicaid, is receiving institutional level care, and has applied for benefits. Improper transfers can therefore result in a period during which the applicant must privately pay for care.
Q. Can I Give Money to My Children Before Applying?
A. Gifts made within five years of applying for nursing home Medicaid may trigger a penalty period under 42 U.S.C. § 1396p(c). Each transfer must be analyzed based on timing, value, and applicable exemptions. Careful planning is required to avoid unintended consequences.
Q. Does Medicaid Cover Home Care?
A. Yes. Medicaid in New York covers home care services for eligible individuals, including personal care services and managed long term care. Medical necessity must be established, and financial eligibility requirements must be met. Coverage and service levels are subject to agency determination and may be appealed if reduced or denied.
Q. How Long Does the Application Process Take?
A. Processing times vary depending on the type of Medicaid requested and the completeness of the documentation submitted. Regulations require agencies to make timely determinations, but delays may occur if additional verification is needed. Applicants have the right to receive written notice of any approval or denial and to request a fair hearing if they disagree with the decision.
Contact Stephen Bilkis & Associates
Medicaid eligibility, long term care planning, and appeals require careful review of federal statutes, state laws, regulations, and case law. Errors can result in denial of benefits or penalties that delay coverage. If you are planning for nursing home care, responding to a denial, or concerned about asset protection, you should consider contacting an experienced New York Medicaid lawyer.
Stephen Bilkis & Associates provides legal representation in Medicaid planning, applications, and fair hearings. The firm reviews financial records, prepares applications, evaluates transfer issues, and represents clients in administrative and court proceedings. The firm is led by managing partner Stephen Bilkis, who is rated Excellent by Avvo, recognized as a Top-Rated Lawyer by Justia.com, and listed among the best lawyers in New York State by Expertise.com and TopLawyer.com.
Contact Stephen Bilkis & Associates to schedule a consultation regarding your Medicaid concerns. If you need guidance on eligibility, planning strategies, or appeals, consulting an experienced New York Medicaid lawyer can help you understand your options under New York law.