New "Minimum Needs" Requirement for Personal Care/CDPAS/MLTC Set to Launch
(Aug. 12, 2025) New clinical eligibility criteria for personal care services, Consumer Directed Personal Assistance Services (CDPAS) and managed long term care (MLTC) will take effect in New York State on Sept. 1st. To qualify for Medicaid coverage of these long-term care services, new applicants will have to demonstrate that they need:
- at least limited assistance with physical maneuvering in relation to more than two activities of daily living (ADLs), or
- at least supervision with more than one ADL, if they have a diagnosis of dementia or Alzheimer's disease.
These requirements apply to individuals seeking enrollment in partially-capitated MLTC plans or in Medicaid Advantage Plus (MAP) plans or new fee-for-service Medicaid coverage of CDPAS or personal care on and after Sept. 1st. These individuals will have to demonstrate their eligibility at initial enrollment or request for services, and at subsequent reassessments. The NY Independent Assessment Program is responsible for the initial assessments for adults seeking these services or MLTC/MAP enrollment. The new minimum needs requirements do not apply to individuals seeking enrollment in PACE programs.
Individuals who require long-term skilled services (e.g., certified home health agency services or medical model Adult Day Health Care), but do not meet minimum needs criteria, will no longer be eligible for MLTC enrollment. They will have to pursue Medicaid coverage of those services on a fee-for-service basis or through PACE programs.
Individuals assessed and authorized for personal care or CDPAS on a fee-for-service basis prior to Sept.1st, and those enrolled in MLTC or MAP plans prior to Sept. 1st and continuously enrolled, will be given "legacy status" and will not have to meet the new minimum needs criteria. In addition, individuals will receive "legacy status" if they were assessed as meeting these criteria prior to Sept. 1st, but were not enrolled in a plan nor authorized for services by Sept.1st, or if they were scheduled for an assessment prior to Sept. 1st but it did not take place through no fault of the applicant.
To qualify based on a diagnosis of Alzheimer's disease or dementia, the individual must provide a DOH-5821 Form signed by a physician. This form must be provided at each reassessment, even if the individual's condition has not changed. MLTC/MAP plans will continue to conduct reassessments and will have to collect these forms at reassessment from consumers who do not have legacy status.
More information about these new requirements is available through previously reporting here. Additional information is available on the DOH website here for MLTC plans, and here for local Departments of Social Services. Questions can be submitted to the Department of Health here. LeadingAge New York will also be gathering members' questions, submitting them to the Department, and circulating information as it becomes available.
Contact: Karen Lipson, klipson@leadingageny.org.