Medicaid Personal Care Services

This article is based on a brochure about Medicaid Personal Care Services. You can read it online or download this printable version. Scroll to the end to view versions in other languages.

How to use this brochure

You can use the Table of Contents to skip straight to your question.

This brochure may contain some words that are new to you. Any time you see a highlighted word (like personal care services), you can roll your pointer over it and a definition will pop up. You can also search our Glossary here.

What are Activities of Daily Living?
What are Personal Care Services?
Am I eligible for Personal Care Services?
How do I get Personal Care Services?
How many hours of home care will I get?
Who is responsible for what?
Who can be my aide?
What if I need more help?
Does my family member need to help?
ICAN can help you.

What are Activities of Daily Living?

Activities of Daily Living are the things you do every day in and around your home. The purpose of home care is to help you with these daily activities. There are two kinds of ADLs that a home care worker might be able to help you with: Level 1 and Level 2.

Level 1 activities (also called Instrumental ADLs or housekeeping) include:

Laundry
Grocery shopping
Light housekeeping
Managing medication
Cooking

Level 2 activities include:

Feeding
Walking and wheelchair use
Bathing
Dressing
Personal hygiene
Using the toilet

What are Personal Care Services?

If you need help safely doing your ADLs, you can get a home care worker to come to your home and help you with those tasks. This is called PCS. The worker is called a Personal Care Aide (PCA). PCAs can help a person with disabilities to safely live in their own home instead of a medical institution.

A PCA is not a nurse. They are a person who has received about 2–3 weeks of training and works for a home care agency. A PCA helps you with the activities included in your plan of care. Your plan of care lists all of the ADL tasks you need help with.

Some people may need other types of care that an aide is not allowed to provide. This might include insulin injections, tube feeding, or other skilled medical care. An aide may bring you medications in a weekly medication box that someone filled for you, and remind you to take them, but cannot put a pill in your mouth. If you need help with these kinds of tasks, you might need other types of home care offered by Medicaid, such as Private Duty Nursing or Consumer Directed Personal Assistance Program (CDPAP).

Am I eligible for Personal Care Services?

Not everyone is eligible for PCS. To qualify, you must meet all the following requirements. Each requirement will be explained in detail after the list.

Self-directing (or someone else who can direct care);
Stable medical condition;
Can live safely at home with home care;
Home care services are medically necessary.

Self-directing

You must be self-directing. Self-directing means that you have the capability to make choices about ADLs, understand the impact of these choices and assume responsibility for the results of these choices. If you cannot do these things, you must have someone you know direct care for you.

Stable medical condition

You must also have a stable medical condition. This means that your health is not expected to suddenly worsen or improve, and that you don’t need frequent changes to your plan of care.

Can live safely at home with home care

If it is not safe for you to continue living in your home, even with help from an aide, then you may not be eligible for PCS. However, your safety does not have to be guaranteed to get home care.

Medically necessary

Medicaid will only pay for the amount of home care services that are medically necessary. Your Medicaid managed care plan will identify how many hours per week of home care services are medically necessary.

How do I get Personal Care Services?

Most people get PCS by enrolling in a Medicaid Managed Care Plan.

About Medicaid Plans

Most people with Medicaid are required to enroll in managed care plans operated by private insurance companies. These companies are paid by Medicaid to cover all medically necessary care within their benefit package. There are different kinds of Medicaid managed care plans for different groups of people. Most people with Medicaid are in a Mainstream Medicaid Managed Care (MMC) plan or a Health and Recovery Plan (HARP). If you have one of these, you do not need to change plans to get PCS. They are already part of your benefit package. So, you can just ask your plan for the services.

If you have Medicare, you have a choice between three different kinds of plans that can provide PCS:

Medicaid Managed Long Term Care (MLTC)
Medicaid Advantage Plus (MAP)
Programs of All-inclusive Care for the Elderly (PACE)

There are also some people who can get PCS without joining a managed care plan:*

Participants in a waiver program, such as the Nursing Home Transition and Diversion (NHTD) Waiver, the Traumatic Brain Injury (TBI) Waiver, or the waiver for people with developmental disabilities (OPWDD)
People who are already receiving hospice services
People who have an immediate need for PCS and are not enrolled in a MMC or HARP. However, this is temporary. They will eventually need to join a managed care plan.
People who have Medicaid but not Medicare and who are not enrolled in MMC or HARP
People ages 18–21

*These are the most common reasons. Call ICAN to see if other exceptions apply to your situation.

NY Independent Assessor Program

The first step for most people with Medicaid to get PCS is to contact the NY Independent Assessor Program (NYIAP). NYIAP is a company that works for Medicaid. They assess people with Medicaid to find out whether they may be eligible to enroll in MLTC or get PCS. If you are already enrolled in MMC or HARP, you have to be assessed by NYIAP before your plan will approve PCS. If you are not enrolled in MMC or HARP, you will have to be assessed by NYIAP before you can enroll in an MLTC or MAP plan to get PCS. If you want to get PCS through a PACE plan, you can enroll in the PACE plan directly without going through NYIAP. People who are excluded from managed care also have to be assessed by NYIAP before they can get PCS.

Here are the steps to get assessed by NYIAP:

Call NYIAP at 855-222-8350. They are open Monday–Friday 8:30am–8:00pm, and Saturday 10:00am–6:00pm.
NYIAP will schedule two appointments with you. They can be held by a video call or in-person. For the video call, you will need to have a computer, smartphone, or tablet that has a camera and microphone, and a connection to the internet.
Community Health Assessment (CHA). This is the first NYIAP appointment. A nurse will ask a long list of questions to find out about your medical condition and what you need help with.
Clinical Appointment (CA). This is the second NYIAP appointment. A doctor or nurse practitioner will ask you a shorter list of questions to find out if you have a stable medical condition and are self-directing.
Outcome Notice. A few days after the second appointment, NYIAP will mail you a notice informing you whether or not you are approved for MLTC enrollment and if you have a stable medical condition.

Next Steps

If you are already enrolled in MMC or HARP, call your plan once you receive the Outcome Notice. They will schedule another appointment to complete your plan of care and determine how many hours of home care you will receive.

If you are not already enrolled in a plan, your next step is to pick an MLTC, MAP, or PACE plan. NYIAP and ICAN can help you pick a plan. Once you pick a plan, you must call them to schedule another appointment. They will use this appointment to complete your plan of care and determine how many hours of home care you will receive.

What if I get denied?

It is possible that NYIAP will send you an Outcome Notice that says you are not eligible to enroll in MLTC or get home care. It is also possible that an MLTC plan will not let you enroll even though NYIAP approved you. In either case, you have the right to appeal that decision. You can do this by requesting a Fair Hearing. This means you can tell a judge why you think the decision was wrong. If the judge agrees with you, they can make NYIAP or the plan change their decision.

If you are enrolled in MMC or HARP and they deny you for home care, you also have the right to appeal. But first you have to file an appeal with the plan before you can request a Fair Hearing.

How many hours of home care will I get?

After the NYIAP assessment, the Medicaid managed care plan will complete your plan of care and determine how many hours of PCS you need. You and the plan will use the information from NYIA’s assessment to complete your plan of care. The plan must consider what tasks you need help with, when you need that help, how frequently, how long it takes, and whether those tasks can be scheduled or are unpredictable. You will work with the plan to make sure that the number of hours they approve is enough to meet any unscheduled or recurring needs, whether they happen at day or night.

When you ask your plan for home care, you should be specific. Tell them exactly how many hours per day and days per week you want, and why. It is best to do this in writing.

What if I need night-time care?

Very rarely, people might need home care services overnight. Medicaid only pays for overnight care if you need help with tasks like toileting, walking, transferring (getting up or down from a chair or bed), turning and positioning in bed, or feeding. There are two types of 24-hour care available: live-in and split-shift.

Live-in: The live-in aide spends 24 hours per day in your home. The aide is only on duty for 12 hours during the day, with 3 breaks for meals. Overnight, the aide is expected to be able to sleep for a total of 8 hours, with 5 hours of uninterrupted sleep. The aide is expected to help you a couple of times overnight when they are not sleeping. There must be separate sleeping space in your home to get live-in services.

Split-shift (also known as continuous care): One aide works the 12-hour shift during the daytime. Another aide works the 12-hour shift during the nighttime. This is called “split-shift” because two aides split the 24-hour care. The nighttime aide is on duty for the entire 12 hours and is not allowed to sleep. You can only get split-shift if your nighttime needs are so frequent that a live-in aide could not get 5 hours of uninterrupted sleep.

What tasks are not covered by PCS?

Your Plan is only required to provide you with assistance for ADLs. This means that there are some tasks that an aide is not allowed to help you with. Your plan will not approve hours for these tasks.

One example is safety monitoring. Safety monitoring means making sure a person is safe without assisting them with an ADL. For example, your plan would not give you PCS during a period of time when you don’t need help with any ADLs, but you just need someone to watch you to keep you from doing something dangerous.

However, an aide is allowed to help you safely perform an ADL, like walking or using the bathroom. This help doesn’t have to be physical; it can be verbal as well. For example, the aide can remind you to use your walker. Another example of tasks that are not covered is companionship. Your plan is not required to provide you with extra time from an aide because you do not want to be alone.

Who is responsible for what?

It takes a team to help you get the care you need at home. It’s important to know the members of this team and who’s responsible for what.

Plan: Your plan determines the amount of home care you receive, and pays for the home care services, medical equipment, and many other things related to your long term care.

Care Manager: Your Care Manager works for your plan. The Care Manager develops your care plan with you and coordinates your care. The Care Manager is usually the first person you contact if you have a problem.

Homecare Agency: Your plan hires a Homecare Agency, which employs the PCA. The Homecare Agency schedules and supervises the aides. You will be assigned a Coordinator at the agency. You can call this person about scheduling issues.

You: You are responsible for letting your plan know of any requests, updating your plan about changes in your condition, answering your plan’s calls, and participating in annual reassessments. You can also have a trusted friend or family member handle these responsibilities.

Who can be my aide?

Most people who receive Medicaid home care have an aide from a home care agency that works with their Medicaid managed care plan.

But Medicaid managed care plans also pay for a program that lets you choose a friend or family member to get paid to be your aide. This is called the Consumer Directed Personal Assistance Program (CDPAP).

CDPAP aides can also perform special tasks, such as insulin injections, tube feeding, and more, if you are able to train them on these tasks. Regular aides cannot perform these tasks.

While you gain flexibility under CDPAP, you also gain responsibilities that you would not have if you received care from a traditional home care agency. These include recruiting, training, scheduling, and supervising the aides.

If you feel that you cannot handle these responsibilities, you can choose someone you know to do them for you, called a designated representative.

All aides must be at least 18 years old and have a valid United States work authorization.

The CDPAP aide may be your child (if at least age 18), another family member, a friend, or someone you hire. But the following people cannot be the CDPAP aide:

Your spouse
Your parent (if you are a child under age 21)
Your designated representative (see definition above) — if you need someone else to direct your care, that person cannot also be your CDPAP aide. Having Health Care Proxy or Power of Attorney does
not automatically make someone your designated representative.

What if I need more help?

If you feel that you need more hours of PCS, a certain type of equipment, or anything else related to your long term care needs, you can make this request to your Care Manager.

The plan must send you a written notice with their decision. If they deny or partially approve your request, this notice is called an Initial Adverse Determination or Coverage Determination Notice.

If you do not agree with your plan’s decision, you can file an appeal.

Does my family member need to help?

Just because your family is supportive or lives with you, does not mean that they need to help you with ADLs.

Some people would like some of their care provided by an aide and the rest of their care provided by a family member. The care that the family member provides must be voluntary. Your plan cannot force the family member to provide this care.

If the family member can no longer provide this care at any time, you can ask your plan for more assistance.

ICAN can help you.

We can:

Answer your questions about Personal Care Services.
Give you advice about your plan options.
Identify and solve problems with your plan.
Help you understand your rights.
Help you file complaints and/or grievances if you are upset with a plan’s action.
Help you appeal an action you disagree with.

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