New York’s Nursing Home Transition and Diversion Waiver, also known as the NHTD Waiver or NHTD Program, provides an alternative to nursing home care for seniors and adults who are physically disabled. Through NHTD, a variety of home and community based services (HCBS) are provided to prevent and delay the need for nursing home placement, as well as to help transition current nursing home residents back to community living. Potential benefits include in-home personal care assistance, home delivered meals, home modifications for safety and accessibility, and assistive technology. Specific to persons transitioning back to living in the community, fees associated with a security deposit, utility set-up fees, and essential home furnishings may be covered.
Many Medicaid Waivers offer a participant-directed option, allowing program beneficiaries to select their own providers, including friends and relatives. The NHTD Waiver does not.
Program beneficiaries can live in their own home or that of a loved one. Persons cannot reside in an adult foster care home or an assisted living residence.
Seniors might also want to consider New York’s Managed Long Term Care Program (MLTC) or Assisted Living Program (ALP) Note that one cannot simultaneously be enrolled in the Nursing Home Transition & Diversion Program and MLTC, nor NHTD and ALP.
The Nursing Home Transition and Diversion Waiver is a Home and Community Based Services (HCBS) 1915(c) Medicaid Waiver. It is not an entitlement program; meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, the program limits the number of participant slots, and once the slots have been filled, a waiting list forms.
What are 1915(c) HCBS Medicaid Waivers?
Historically Medicaid only paid for long-term care in nursing homes. 1915(c) HCBS Medicaid Waivers allow states to offer benefits outside of these institutions. “HCBS” stands for Home and Community Based Services. The goal of HCBS is to delay or prevent institutionalization, and to that end, care may be provided in one’s home, the home of a relative, assisted living, or adult foster care / adult family living. Waivers can target specific groups who require a Nursing Home Level of Care and are at risk of institutionalization, such as persons who are elderly, disabled, or have Alzheimer’s disease. Waivers are not entitlements. This means that meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.
In addition to case management (service coordination), follows is a list of potential benefits available via the NHTD Waiver. An individualized service plan determines which services and supports a program participant receives.
– Assistive Technology – may include personal emergency response systems
– Community Integration Counseling
– Community Transitional Services – assistance with security deposit, utility set-up fees, and essential furnishings for persons transitioning from a nursing home to community living
– Home and Community Support Services – supervision / assistance with daily living activities (bathing, dressing, toileting, mobility, preparing meals, housekeeping, laundry, shopping)
– Home Delivered Meals / Congregate Meals
– Home / Vehicle Modifications
– Home Visits – wellness monitoring, diagnosis, and treatment by medical professionals
– Independent Living Skills Training Services
– Moving Assistance Services – assistance with packing and moving (only for persons who already live in the community)
– Nutritional Counseling / Educational Services
– Peer Mentoring
– Positive and Behavioral Interventions and Supports Services
– Respiratory Therapy Services
– Respite Care – in-home and out-of-home care to relieve a non-paid primary caregiver
– Structured Day Program Services / Day Habilitation
– Transportation – non-medical and medical
– Wellness Counseling Service
The NHTD Waiver is for NY residents with physical disabilities (aged 18-64) and seniors (aged 65+) who at risk of nursing home placement. Program beneficiaries who are physically disabled and enroll in the program prior to the age of 65 can continue in the program when turning 65. Additional eligibility criteria are as follows below.
The American Council on Aging now offers a quick and easy NY Medicaid Eligibility Test for seniors who require long-term care.
Income
In 2024, the individual applicant income limit is $1,732 / month, and the couple income limit with both spouses as applicants is $2,351 / month. When only one spouse is an applicant, the individual income limit of $1,732 / month is used; the income of the non-applicant spouse is not counted towards the applicant spouse’s income eligibility. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance. In New York, this is called a Community Spouse Monthly Income Allowance (CSMIA).
In 2024, the CSMIA is $3,853.50. This is the maximum amount of monthly income that can be transferred to the non-applicant spouse and is intended to bring the non-applicant spouse’s income up to this amount. Non-applicant spouses who have their own monthly income equal to or greater than $3,853.50 are not entitled to a Spousal Income Allowance. Furthermore, it is requested that non-applicant spouses with monthly income over $3,853.50 contribute 25% of the “excess” towards the applicant spouse’s care costs.
Assets
In 2024, the asset limit is $31,175 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $42,312. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are still limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can retain up to $31,175 in assets and the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA) to prevent spousal impoverishment.
The CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $154,140. If 50% of the couple’s assets falls under $74,820 the non-applicant spouse can keep all of the couple’s assets, up to this amount.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value prior to applying for long-term care Medicaid. This is because NY Medicaid is implementing a 30-month Look-Back Rule for applicants of home and community based services. This should be implemented no earlier than March 31, 2024. Once implemented, violating this rule will result in a Penalty Period of Medicaid ineligibility.
To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our Medicaid Spend Down Calculator.
Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. For eligibility purposes, New York Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has “Intent” to Return, and in 2024, their home equity interest is no greater than $1,071,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– A non-applicant spouse lives in the home.
– The applicant has a permanently disabled or blind child living in the home.
– The applicant has a minor child (under 21 years old) living in the home.
An applicant must require a Nursing Facility Level of Care (NFLOC) to be eligible for NHTD services. To make this determination, a functional needs assessment is done. For persons living at home or in the community, the Uniform Assessment System (UAS-NY), is completed by a registered nurse. For persons living in a nursing home, the Hospital and Community Patient Review (H/C PRI) and SCREEN may be utilized. One area of consideration is one’s ability / inability to complete their Activities of Daily Living (ADLs). ADLs include bathing, dressing, mobility, toileting, and eating. Cognitive deficits, which are commonly seen in persons with Alzheimer’s disease or a related dementia, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
When persons have income over the limit, Pooled Income Trusts can help. “Excess” income is deposited into the trust, no longer counting as income. NY also has a Medicaid Spend-Down Program that permits applicants to spend “excess” income on medical bills each month to meet the income limit. The amount that must be paid can be thought of as a deductible. Once one’s “deductible” has been paid for the month, New York Medicaid will pay for services and supports.
When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option, but for married couples who have a significant amount of assets over Medicaid’s limit, is a Medicaid Divorce. This strategy protects assets for the non-applicant spouse. There are many other options when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in New York to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but also protect assets from Medicaid’s Estate Recovery Program. These strategies often violate Medicaid’s Look-Back Rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s).
Prior to submitting an application for the NHTD Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, previous bank statements, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.
Since the NHTD Waiver is not an entitlement program, there may be a waitlist for program participation. The NHTD Waiver is approved for a maximum of approximately 3,234 program participants per year. In the case of a waitlist, it is thought an applicant’s access to a participant slot is first come, first served.
Persons must be enrolled in NY Medicaid and eligible for community-based long-term care in order to apply for the Nursing Home Transition & Diversion Waiver. Persons can apply for Medicaid via their Local Department of Social Services (LDSS).
For persons already enrolled in Medicaid and eligible for long-term care in the community, a referral should be made to begin the application process for NHTD. Persons can make a referral on their own behalf or on someone else’s behalf by contacting their area’s Regional Resource Development Center (RRDC). Persons can also submit a referral form directly to RRDC. Additionally, current nursing home residents can speak to their facility’s discharge planner, who can make a referral on their behalf.
Persons can learn more about the Nursing Home Transition and Diversion Waiver here or contact their RRDC or Regional Open Doors Transition Center for additional information.
The New York State Department of Health (NYSDOH) administers the NHTD Waiver Program. Regional Resource Development Centers (RDDCs) are contracted by NYSDOH to manage the application process and administer the program in their area. NHTP can be considered a Money Follows the Person program, which is the name commonly used in other states.
The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. Once approved for Medicaid, one can begin the NHTD Program application process, which may take another few months. If no participant slots are available, one will have to wait for a slot to open up to receive benefits.