State Initiates Implementation of Revised Minimum Needs Requirement for Personal Care Services and MLTC Eligibility and Enrollment
(July 1, 2025) The Department of Health (DOH) announced on June 30th the initiation of implementation of a new revised Minimum Needs requirement for Personal Care and Consumer Directed Personal Assistance Services (PCS/CDPAS) and Managed Long Term Care (MLTC) enrollment eligibility as outlined in Social Services Law (SSL) § 365-a; SSL § 365-f; 18 NY Codes, Rules, and Regulations (NYCRR) §§ 505.14 and 505.28; and Public Health Law (PHL) § 4403-f. As members may recall, these requirements were enacted in the 2020 NYS budget, but were not implemented due to continuity of care requirements during COVID-19.
Policy communications were sent to plans in the form of MLTC guidance and letters to Medicaid Managed Care (MMC) plans and Local Departments of Social Services (LDSSs). However, providers should take note of these important changes.
Providers and plans should carefully review the DOH letter to MMC plans and LDSSs and MLTC Policy 25.04: Minimum Needs Requirement Update to the Eligibility Requirements for MLTC Enrollment.
Effective Sept. 1, 2025, any individual initially seeking PCS/CDPAS and/or MLTC enrollment through the assessment process must also be assessed to meet the following Minimum Needs criteria to be eligible for PCS/CDPAS and/or MLTC enrollment:
- Needing at least limited assistance with physical maneuvering with more than two Activities of Daily Living (ADLs); or
- Individuals with a diagnosis by a physician of dementia or Alzheimer’s as needing at least supervision with more than one ADL.
The Minimum Needs requirement does not apply to Program of All-Inclusive Care for the Elderly (PACE) enrollment. However, PACE programs should carefully review the new policy. While PACE is not subject to the Minimum Needs requirement for enrollment, individuals with PACE will be granted Plan Legacy and Service Legacy following the same process as other MLTC plans. This status will allow individuals enrolled in PACE prior to the implementation to transfer within MLTC lines of business.
This new requirement will not apply to individuals who are receiving PCS/CDPAS and/or are continuously enrolled in an MLTC plan as of Sept. 1, 2025. These individuals will continue to be eligible under the previous criteria eligibility requirements for MLTC enrollment.
Individuals enrolling into a MLTC Partial Capitation (MLTCP) or Medicaid Advantage Plus (MAP) plan on or after Sept. 1, 2025 must meet the Minimum Needs requirements at initial and subsequent assessments in addition to the need for Community-Based Long-Term Services and Supports (CBLTSS) for more than 120 days.
The MLTC guidance provides steps for granting or removing Service and Plan Legacy status and providing Alzheimer's or dementia documentation. The guidance also addresses responsibilities of the NY Independent Assessor Program, variance requests, and MLTC responsibility for reassessments.
Providers are encouraged to check the Department website for additional details.
Plans and providers should carefully review both the letter and MLTC Policy on the new changes.
Contact: Meg Everett, meverett@leadingageny.org, 518-867-8871