Long-term care services in New York provide essential medical and personal support to elderly and disabled residents, representing a substantial portion of the state’s annual Medicaid spending. This page covers CBC’s work on Medicaid eligibility standards, nursing home payment rates, home care service utilization, managed long-term care enrollment, and the coordination of care for dually eligible individuals.
This page was created with AICBC Insights uses AI to group, analyze and present data and recommendations from CBC's publications. Always reference the cited sources to verify important details..
The State should focus on improving efficiency in ways that minimize service reductions, including savings from care redesign and labor productivity from work rule and benefit changes.
The State should repeal the 'spousal refusal' provision, which would yield growing savings in long-term care.
The State should conduct a prompt retrospective evaluation of the Consumer Directed Personal Assistance Program (CDPAP) to assess whether costs are appropriate and what program eligibility or service-level parameters should change.
The State should manage long-term and personal care services relative to indexed growth on disaggregated inflation measures for nursing homes and home care.
The plans should be better marketed with more extensive consumer education.
Competition from MLTC plans could be eliminated by requiring them to convert to integrated arrangements.
Marketing material from DOH explaining the benefits of each option for individuals with various types of health conditions could be helpful for the dually eligible population in making their enrollment decisions.
The state should require MLTC plans to offer companion D-SNPs in their service area.
The state should limit contracting with D-SNPs to plans also having MLTC plans.
The state should allow passive enrollment of MLTC plan members in aligned D-SNPs.
The state should encourage enrollment among the current Medicaid MCO enrollees who reach age 65 and are discontinued from MCO enrollment.
Key Data
In October 2023, the CBC noted that Medicaid cost $101 billion that year, making it the single largest program in the State's budget, with long-term care services serving as a significant contributor to this spending growth.
In a March 2020 public comment, the CBC highlighted that long-term care represents an increasing share of the Medicaid Global Cap budget, rising from 44.1% in fiscal year 2015 to an estimated 47.6% in 2019.
According to a March 2020 report, daily nursing home costs in New York are approximately 50% higher than the national average, with rising minimum wage levels continuing to drive higher spending.
In March 2020, the CBC reported that New York's personal care spending per capita was more than 6 times greater than the national average in 2016, and per-capita costs had doubled since then.
In an April 2019 discussion paper, the CBC noted that enrollment in Managed Long-Term Care (MLTC) plans increased from 42,523 in 2010 to 199,281 in 2018, largely driven by the Medicaid Redesign Team's mandate.
New York State's Medicaid program, which costs $101 billion annually, requires greater transparency regarding the utilization and spending of home care services to better manage long-term care costs. Signing legislation to mandate annual reporting on these services is a necessary first step toward understanding trends and ensuring the sustainability of the health care system.
Recommendations related to Long-Term Care Services
The Governor should sign A1926A/S1683A to require annual reporting on home care services.
The Department of Health should aggressively enhance its transparency efforts to provide the public access to cross-tabular, longitudinal spending, and utilization data disaggregated by geography, demographics, and other categories.
Key Data
$101 billion
— The cost of the Medicaid program in New York State for the current year.
The Medicaid Redesign Team proposed a package of savings to address fiscal gaps, with the largest portion—$647 million—derived from reforms to long-term care services. However, federal COVID-19 response legislation complicates the implementation of these measures, as approximately $474 million in proposed savings related to long-term care eligibility requirements may be prohibited under federal law.
Recommendations related to Long-Term Care Services
The State should institute an HCBS Eligibility Lookback Period of 60 Months to be consistent with the look-back period for nursing homes.
The State should eliminate Spousal and Legally Responsible Relative Refusal to ensure consistent eligibility standards for long-term care.
The State should cap statewide Managed Long Term Care (MLTC) enrollment growth at a target percentage to control costs.
The State should change eligibility criteria for Personal Care Services and the Consumer Directed Personal Assistance Program (CDPAP) within MLTC partial plans.
The State should require all Uniform Assessment System (UAS) Community Health Assessments and reassessments to be conducted by an independent assessor.
Key Data
$647 million
— The total projected savings from the Medicaid Redesign Team's package related to long-term care.
$474 million
— The amount of Medicaid savings likely prohibited under federal law because they relate to eligibility requirements for those seeking long-term care services.
$215 million
— The projected savings from capping statewide Managed Long Term Care (MLTC) enrollment growth at a target percentage.
$154 million
— The projected savings from changing eligibility criteria for Personal Care Services and the Consumer Directed Personal Assistance Program (CDPAP) in MLTC partial plans.
New York's Medicaid spending on long-term care is rising rapidly, now consuming nearly half of the total Medicaid budget, driven by high utilization and generous eligibility rules like 'spousal refusal.' To address these fiscal challenges, the state should implement reforms to improve efficiency and target resources to those most in need, rather than relying on broad, unsustainable spending growth.
Recommendations related to Long-Term Care Services
The State should focus on improving efficiency in ways that minimize service reductions, including savings from care redesign and labor productivity from work rule and benefit changes.
The State should repeal the 'spousal refusal' provision, which would yield growing savings in long-term care.
The State should conduct a prompt retrospective evaluation of the Consumer Directed Personal Assistance Program (CDPAP) to assess whether costs are appropriate and what program eligibility or service-level parameters should change.
The State should manage long-term and personal care services relative to indexed growth on disaggregated inflation measures for nursing homes and home care.
Key Data
47.6 percent
— Estimated share of the Medicaid Global Cap budget consumed by long-term care in the most recent year.
50 percent
— Amount by which daily nursing home costs in New York exceed the national average.
$500 million
— Cost for the health home care coordination model in the first five years after its 2011 launch.
44.1 percent
— Share of the Medicaid Global Cap budget consumed by long-term care in fiscal year 2015.
New York State should examine high-growth spending areas like long-term care to improve efficiency and minimize service reductions within the Medicaid program. Furthermore, the state should maintain incentives for residents to purchase private long-term care insurance to help mitigate the impact of rising Medicaid costs.
Recommendations related to Long-Term Care Services
The Medicaid Redesign Team should examine high-growth spending areas, including long-term care, personal care, and home care, which may benefit from tightened eligibility and other reforms.
The State should not remove incentives for New Yorkers to acquire long-term care insurance, given the rising costs of Medicaid-funded services.
New York's dually eligible population, which includes many individuals requiring long-term care, faces challenges with poorly coordinated care and high costs. To improve outcomes, the state should consider strategies like better marketing of integrated plans, constraining competition from alternative arrangements, and fostering partnerships between different types of managed care plans.
Recommendations related to Long-Term Care Services
The plans should be better marketed with more extensive consumer education.
Competition from MLTC plans could be eliminated by requiring them to convert to integrated arrangements.
Marketing material from DOH explaining the benefits of each option for individuals with various types of health conditions could be helpful for the dually eligible population in making their enrollment decisions.
The state should require MLTC plans to offer companion D-SNPs in their service area.
The state should limit contracting with D-SNPs to plans also having MLTC plans.
The state should allow passive enrollment of MLTC plan members in aligned D-SNPs.
The state should encourage enrollment among the current Medicaid MCO enrollees who reach age 65 and are discontinued from MCO enrollment.
Key Data
880,000
— Number of dually enrolled persons in New York State in 2018.
15 percent
— Share of New York's Medicaid population that is dually enrolled.
36 percent
— Share of New York's Medicaid program costs consumed by the dually enrolled population.
224,857
— Number of enrollees in Managed Long-term Care (MLTC) plans in New York as of January 2019.
263,203
— Number of enrollees in Advantage D-SNPs in New York as of November 2017.
53,000
— Number of dually eligible persons enrolled in a health home in 2018.
New York State has mandated enrollment in managed long-term care plans for dual-eligible individuals requiring extensive care, with approximately 198,000 people enrolled as of October 2017. However, the Fully Integrated Duals Advantage program, designed to integrate long-term and acute care, has seen significantly lower participation than projected, with only 4,500 enrollees compared to an initial goal of 100,000.
Key Data
198,000
— Number of people enrolled in a managed long-term care program as of October 2017.
4,500
— Number of people enrolled in the Fully Integrated Duals Advantage program as of October 2017, compared to initial projections of 100,000.
New York's requirement for local governments to fund a portion of Medicaid costs creates an inequitable financial burden that varies significantly by county and fails to align with cost-containment incentives. The state should eliminate this local funding requirement to ensure a more sustainable and equitable fiscal structure, particularly regarding the administration and financing of long-term care services.
Recommendations related to Long-Term Care Services
The State should assume responsibility for the local share liability over a period of four or five years to eliminate the local funding requirement for Medicaid, including long-term care services.
Full state financing is the best way to achieve continued cost control in a program fully controlled by the State, which would better align decision-making responsibility for long-term care services with the obligation to pay for them.
Centralizing administrative control at the state level should increase incentives to control costs in long-term care services and other areas.
Key Data
9 percent
— The portion of the cost of long-term care services that localities are required to pay.
$375 million
— The amount shifted from localities to the State in fiscal year 2009 due to policy changes regarding long-term care services.
13 percent
— The increase in local Medicaid administrative employees between 2005 and 2010.
$555
— The per capita local Medicaid burden for New York City.
This presentation, from the CBC panel discussion "The Berger Commission: 10 Years On," reviews how health care services in New York City have evolved since the New York State Commission on Health Care Facilities in the 21st Century, known as "The Berger Commission" issued its recommendations in 2006.
New York's Medicaid program has successfully implemented managed care and delivery system reforms, including the expansion of long-term care managed care enrollment from 39,297 to 169,286 between 2010 and 2015. Despite these gains, significant challenges remain in enrolling populations with complex needs, such as those requiring long-term care, necessitating continued federal coordination and rigorous monitoring of new delivery systems.
Recommendations related to Long-Term Care Services
New efforts should be made to work with federal officials to develop procedures that encourage and perhaps require such enrollment in managed care and Health Homes in the future.
Continued strong monitoring of the evolution of these organizations and their action plans is essential, and their ability to achieve measureable improvements is still to be tested.
Given the potential fiscal and health outcome benefits from the arrangement, renewed efforts to expand enrollment in Health Homes seem warranted.
Key Data
40,000
— Medicaid eligible people enrolled in plans specializing in long-term care services in 2010.
169,286
— Managed long-term care enrollment by the end of 2015, representing a quadrupling from 39,297 in 2010.
162,000
— Number of people enrolled in a managed long-term care program out of 170,000 intended to be reached as of the end of 2015.
7,500
— Number of people enrolled in the Fully Integrated Duals Advantage (FIDA) program as of late 2015, compared to projections of 100,000.
New York's "spousal refusal" provision allows families to bypass Medicaid income and asset limits for long-term care, creating an unfair loophole that discourages the purchase of private insurance. Repealing this practice would generate significant state savings and better align Medicaid eligibility with its intended purpose of supporting low-income individuals.
Recommendations related to Long-Term Care Services
The Legislature should end this costly and unfair practice of Medicaid spousal refusal.
Key Data
$21,984
— Annual income eligibility limit for couples over 65 for Medicaid.
$21,750
— Asset eligibility limit for couples over 65 for Medicaid.
$35,760
— Annual income limit for Medicaid when one spouse requires institutionalized care.
$119,220
— Asset limit for Medicaid when one spouse requires institutionalized care.
$10 million
— Estimated annual savings from ending spousal refusal in fiscal years 2016-2017 and 2017-2018.
20 percent
— Personal income tax credit offered by New York State for long-term care insurance premiums.
New York's Medicaid redesign includes targeted measures to control rising long-term care costs, such as capping payments to home health agencies and restricting personal care services. These reforms aim to address significant spending growth in nursing homes and home-based care while improving the overall efficiency of the state's Medicaid program.
Recommendations related to Long-Term Care Services
The effective savings measures regarding long-term care services should be implemented speedily.
Future efforts should be pursued to reverse the new assessments that push up the cost of care.
Future savings in line with the goal of the innovative cap strategy will require broad changes in the way providers are paid for long-term care.
The state must undertake even greater efforts to limit excessive utilization of long-term care through managed care and other new controls.
The new Medicaid spending cap should be tested carefully in the coming year to ensure it effectively manages long-term care expenditures.
Key Data
$12 Billion
— Total long-term care costs in 2008, representing roughly a quarter of all Medicaid spending in the state.
40%
— Increase in spending on personal care services from 2003 to 2008.
30%
— Amount by which New York's nursing home rates exceeded the national norm in 2007.
76%
— Increase in per recipient costs in the Certified Home Health Agencies (CHHA) program from 2003 to 2008.
$57 Million
— Estimated annual savings from restricting personal care services in New York City.
$28 Million
— Estimated first-year savings from eliminating the practice of spousal refusal for Medicaid eligibility.
New York's Medicaid spending on nursing home care significantly exceeds national averages, yet the quality of care provided remains mediocre. Reforming the outdated payment system to a statewide base rate, while incorporating quality-based incentives, is necessary to achieve essential cost savings and improve patient outcomes.
Recommendations related to Long-Term Care Services
The Medicaid Redesign Team should consider lowering nursing home payment rates even further to align with national norms.
The Medicaid Redesign Team should include a quality care pool to reward facilities for improving care to residents.
The Medicaid Redesign Team should strengthen the payment reform proposal to achieve greater savings and to provide financial incentives for improved care.
Key Data
$2.85 Billion
— The annual Medicaid savings goal identified for the Medicaid Redesign Team.
$203.21
— The average per diem Medicaid rate in 2007, which was 30 percent above the national average.
$6.7 Billion
— The amount New York spent on residential nursing home care in 2008.
$50,563
— The amount spent per Medicaid recipient in a nursing facility in 2008.
3.6 hours
— The average amount of direct nursing care provided per day in nursing homes statewide in 2008.
$100 Million
— The estimated annual savings from the proposed nursing home payment system.
New York's Medicaid program faces high costs driven largely by long-term care services for the elderly and disabled, necessitating reforms to nursing home payments and personal care authorization. By tightening eligibility rules and implementing mandatory managed care for dual-eligible individuals, the state can achieve significant savings without compromising necessary care.
Recommendations related to Long-Term Care Services
The state should adjust nursing home payments to bring them more in line with national norms.
The state should implement a significant rate reduction for nursing homes, using some savings to increase nursing staff levels and fund a quality outcomes bonus pool.
The state should move more quickly to takeover Medicaid administration from counties and New York City.
The state should create more uniform and tougher rules for determining long-term care eligibility, particularly regarding spousal refusal and asset transfers.
The state should promptly improve administrative practices with respect to the authorization of home care hours.
The state should immediately coordinate with the federal government to create a mandatory managed care option for dual-eligible individuals that covers both acute and long-term care.
Key Data
21%
— Amount by which New York’s nursing home rates exceeded the national average in 2008.
$2.3 Billion
— Total personal care expenditures in 2008.
83%
— Share of all personal care expenditures that occur in New York City.
49
— Number of hours of personal care per week received by more than half of recipients in New York City.
66%
— Statewide Medicaid managed care enrollment rate.
Long-term care for the elderly and disabled has become an increasingly expensive component of New York's Medicaid program, with annual costs reaching $12.5 billion. Between 2003 and 2008, per-recipient spending for these services grew significantly, including a 76 percent increase for certified home health agencies and a 40 percent rise for non-institutional personal care.
Recommendations related to Long-Term Care Services
New York should utilize rates and utilization as levers to bring Medicaid costs under control, particularly for long-term care and services for the elderly and disabled.
The state should address the number of people enrolled, payment rates to providers, and service utilization to contain Medicaid costs for long-term care.
Governor Cuomo should create a multiyear plan to restructure the Medicaid system to provide better health-care outcomes and lower costs.
The state needs to bring down the cost of care where it is exorbitant to meet obligations to the neediest New Yorkers without slashing other public services.
Key Data
$12.5 billion
— Annual cost of long-term care for the elderly and disabled.
19 percent
— Growth in per-recipient spending for nursing-home care between 2003 and 2008.
40 percent
— Growth in per-recipient spending for non-institutional personal care between 2003 and 2008.
76 percent
— Growth in per-recipient spending for certified home health agencies between 2003 and 2008.
New York's Medicaid spending is heavily concentrated on the elderly and disabled, with long-term care services representing a significant and rapidly growing portion of these expenditures. To achieve meaningful fiscal relief, the state must implement a multi-year plan that directly addresses provider payment rates and utilization within these high-cost service categories rather than focusing on peripheral expenses.
Recommendations related to Long-Term Care Services
Rates and utilization—specifically in long-term care and other services for the elderly and disabled—should be the primary focus for future cost control initiatives.
A multi-year plan that takes this politically powerful bull directly by the horns—restructuring the system to provide better health, better outcomes and lower costs—should be developed.
Any cost containment proposals should address the three factors that drive Medicaid costs: enrollment, provider payment rates, and utilization.
Policymakers should avoid proposals that address only the fringes of program expenses, such as fraud or the limited costs of healthy mothers and children, as these will not yield significant fiscal relief.
Key Data
$12.5 billion
— Total annual costs for long-term care services.
$47,909
— Average cost per recipient for long-term care in an institutional setting.
$50,563
— Average cost for recipients in nursing homes in calendar year 2008.
$25,195
— Average cost per recipient for non-institutional care.
$30,004
— Average cost for personal care services.
$63,467
— Per recipient cost for community rehabilitation services in calendar year 2008.
New York State's Medicaid spending on long-term care has risen substantially in recent years, even as the number of recipients for these services has declined. This trend is particularly pronounced in non-institutional care, where spending growth has significantly outpaced changes in service utilization.
Key Data
28.0 percent
— Medicaid spending for personal care services increased by 28.0 percent between 2003 and 2008, while the number of recipients decreased by 8.2 percent.
76 percent
— Per-recipient spending growth for Certified Home Health Agencies (CHHAs) reached 76 percent between 2003 and 2008.
55.9 percent
— Medicaid spending for Certified Home Health Agencies (CHHAs) increased by 55.9 percent between 2003 and 2008, despite an 11.4 percent decrease in the number of recipients.
35.5 percent
— Long term home health care spending increased by 35.5 percent between 2003 and 2008, while the number of recipients decreased by 1.2 percent.
56.9 percent
— Other non-institutional long term care services experienced a 56.9 percent increase in Medicaid spending between 2003 and 2008, with a 9.2 percent decrease in the number of recipients.
72.9 percent
— Per-recipient spending for other non-institutional long term care services increased by 72.9 percent between 2003 and 2008.
New York's Medicaid spending per beneficiary is 69 percent higher than the national average, largely due to high costs associated with long-term care. To address this, the state should close eligibility loopholes for long-term care and control the utilization of personal care services to achieve significant annual savings.
Recommendations related to Long-Term Care Services
Eligibility loopholes for long-term care that allow middle-class and wealthy New Yorkers to benefit from the program should be closed.
Tightening eligibility to individuals with homes worth less than $500,000 and applying the look-back period for asset transfers to eligibility for home care would save $400 million annually.
Controlling excessive utilization of personal care services and expanding managed care would save $600 million annually.
Key Data
69 percent
— Medicaid spending per beneficiary in New York is higher than the national average, driven in large measure by high expenses for long-term care.
$400 million
— Annual savings from tightening eligibility for long-term care to individuals with homes worth less than $500,000 and applying the look-back period for asset transfers to eligibility for home care.
$600 million
— Annual savings from controlling excessive utilization of personal care services and expanding managed care.
$1 billion
— Total annual savings over the next few years from closing long-term care eligibility loopholes and controlling personal care utilization.
New York's Medicaid program, which spends significantly more on long-term care than the national average, should tighten eligibility rules for nursing home and home care services to prevent middle-class families from avoiding financial responsibility. Additionally, the state should lower provider payment rates to competitive levels and reduce the excessive number of authorized personal care hours to align with national norms.
Recommendations related to Long-Term Care Services
More careful design and better enforcement of eligibility rules for the elderly and disabled will reduce the number of such people receiving Medicaid funded nursing home and home care services.
Limiting Medicaid provider payments to rates based on competitive costs would save about $2.5 billion annually.
Efforts should be made to build the capacity among managed care organizations to manage care for these groups effectively.
Bringing use of personal care services more in line with national norms would save about $1.0 billion annually.
Spousal refusal should be permitted only under limited circumstances, and the three-year look-back provision relating to asset transfers should be applied to home care, be enforced more vigorously, and the financial penalties should be greater.
Key Data
$608 million
— Annual savings from fewer long-term care eligibles due to more careful design and better enforcement of eligibility rules.
$25,137
— New York's annual cost for long-term care individuals compared to a national average of $12,647.
$1.4 billion
— Annual savings from lowering nursing home rates to competitive levels.
$423 million
— Annual savings from lowering intermediate care facility rates to competitive levels.
$1.0 billion
— Annual savings from bringing personal care services in line with national norms.
30 hours per week
— Average number of home care hours paid for by Medicaid in New York compared to 11 hours per week in the rest of the country.
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