Minimum Needs Requirements for NY Medicaid home care, explained

• Most adults: the assessment must find you need at least "limited assistance with physical maneuvering" with more than two everyday activities. That means three or more.
• Adults with a doctor-confirmed diagnosis of dementia or Alzheimer's disease: the assessment must find you need at least "supervision" with more than one everyday activity. That means two or more. The diagnosis has to be on a specific state form, DOH-5821, or it is not counted.
• People already receiving services before September 1, 2025 have what the state calls Legacy Status and are not held to the new test.
• PACE (a program for people 55 and older) is not covered by the new rule. It has its own requirements.

Nothing on this page is an eligibility decision. Only the assessment decides.

The Department of Health's Minimum Needs page states that personal care and consumer directed services are available "for members assessed as needing at least limited assistance with physical maneuvering with more than two ADLs," or "for members with a Dementia or Alzheimer's diagnosis, assessed as needing at least supervision with more than one ADL." ADL stands for activity of daily living.

DOH's regulation says who scores it: "The entity designated by the Department of Health to provide independent assessment services shall be responsible for determining whether individuals meet minimum needs requirements." In practice that is NYIA's nurse assessment, which the state calls the Community Health Assessment.

Before this change, DOH's page says, "authorization for PCS/CDPAS required members to need assistance with one or more personal care services, home health aide services or skilled nursing tasks." One task was enough. Now the count matters.

DOH's notice FAQ lists the activities the assessor looks at in consumer language:

• bathing or showering
• personal hygiene such as hair, tooth, and nail care
• getting dressed
• eating your meals
• getting in and out of bed or getting up from a chair
• walking and getting around in your home
• using the bathroom

Housework, cooking, shopping, managing money, and taking the bus are real needs, but they are not on this list. They are "instrumental" activities, and they do not count toward the Minimum Needs test.

The assessment uses a scale from the state's standard tool. DOH's training materials describe the steps this way: "Supervision - Oversight/cuing required. Limited assistance - Help required on some occasions. Extensive assistance - Help required throughout task, but performs 50% or more." Above that come maximal assistance and total dependence.

So for most adults, the bar is help from another person's hands on some occasions with three or more of the activities above. Someone standing nearby and reminding does not count as limited assistance. For a person with a confirmed dementia diagnosis, that standing-nearby help does count, and only two activities are needed.

One honest caution: DOH has not published a consumer definition of "physical maneuvering," and the scale wording above comes from older training slides. The assessor applies the tool; families cannot score it at home. What you can do is describe a normal day accurately, including what happens on the bad days.

The lower threshold for dementia or Alzheimer's only works with paperwork. The state form is called "Alzheimer's Disease and Dementia Diagnosis Verification," form DOH-5821. NYIA's page on it says: "If you are not able to provide this form at the time of your assessment appointments, the diagnosis cannot be considered."

What the form itself says:

• The diagnosing provider "MUST BE A MD OR DO." The provider who fills it out "MUST BE A MD, DO, NP, OR PA."
• Failing to "complete and present this form to the assessor at the time of the patient's Community Health Assessment (CHA) may impact the patient's eligibility."

DOH adds that the doctor does not need to be a Medicaid provider, and that the form is needed "at each assessment where the condition is present." NYIA's page says you can fax it ahead to 917-228-8601 or hand it to the nurse at the visit. Ask the doctor's office for it before you schedule, not after.

DOH's personal care page puts it this way: "The Minimum Needs Requirement apply to Medicaid recipients aged 21 or older, seeking [personal care] and [consumer directed personal assistance]. This requirement also applies to all Medicaid recipients aged 18 and older who want to enroll in a [Medicaid Advantage Plus] or [Managed Long Term Care plan]."

For MLTC and Medicaid Advantage Plus, MLTC Policy 25.04 adds a second condition that already existed: the person must need community-based long-term services "for more than 120 days."

Who it does not apply to:

• PACE. Policy 25.04 says the new criteria "do not apply to enrollment in Programs of All-Inclusive Care for the Elderly (PACE) plans." PACE still requires a nursing home level of care, a need for services for more than 120 days, and age 55 or older. New York Medicaid Choice (1-888-401-6582) can say whether PACE operates in your county.
• Children. DOH says the assessment process for children "has not changed and is not impacted by" the new requirements.
• Certain waiver programs. DOH's page notes that the Nursing Home Transition and Diversion, Traumatic Brain Injury, and OPWDD waivers do not use the NYIA Community Health Assessment.

DOH defines Legacy Status as "a classification of eligibility criteria that applies to an individual who was enrolled in PCS, CDPAS, or MLTC prior to September 1, 2025." There are two kinds:

• Service Legacy: personal care or consumer directed services were authorized before September 1, 2025.
• Plan Legacy: the person was enrolled in an MLTC plan, including PACE, before September 1, 2025.

DOH's Medicaid Update says Service Legacy holders "will not have to meet the Minimum Needs requirements if their services end after September 1, 2025 and they come back for services at a future date." Plan Legacy is more fragile. Policy 25.04 says it "will only be removed by the MLTC plan when a member is disenrolled from the MLTC Program," and that switching plans "with no break in enrollment" keeps it. The Medicaid Update is blunt about the other case: people disenrolled from MLTC "will lose their MLTC Plan 'Legacy' status and will need to meet the new Minimum Needs eligibility criteria to re-enroll."

Two edge cases DOH's page covers: a person with a valid assessment done "after August 31, 2024, and before September 1, 2025" keeps the old rules "if authorized within one year of that assessment," and so does someone whose appointment was "rescheduled through no fault of their own to after September 1, 2025." If either sounds like your situation, say so to NYIA and to the plan, and keep the dated letters.

Medicaid personal care has a light tier called Level I, which covers housekeeping, laundry, and shopping and is capped in regulation at eight hours a week. DOH's response to public comment says people "who only have need for Level I services do not meet the minimum needs criteria." People who meet the full test can get both levels. Legacy Level I recipients keep what they have.

After the two NYIA appointments, a notice arrives. DOH's sample language for a person who did not meet the test reads: "You do not need help with more than two activities of daily living, such as bathing or getting dressed. You also do not need supervision with more than one activity of daily living if a diagnosis of Alzheimer's Disease or dementia was confirmed during your assessment."

The notice carries a deadline. NYIA's FAQ says a fair hearing must be requested "within 60 days of receiving the assessment outcome notice," by phone, fax, or mail, and that an informal conference is also available. That is as far as this post goes on appeals; the notice itself and NYIA at 1-855-222-8350 (TTY 1-888-329-1541) explain the process, and a change in condition is grounds to ask for a new assessment. DOH's NYIA page says an assessment "may be valid from six (6) months to up to twelve (12) months," and a person can be reassessed "upon a change in medical condition, upon release from institutional care, or upon their request."

• Coaching the answers. Assessors are trained to see the difference between a rehearsed "I cannot do anything" and a real day. Describe what actually happens.
• Forgetting the dementia form. Without DOH-5821 in the assessor's hands, the diagnosis is not considered, even if it is in the chart.
• Counting the wrong things. Cooking, cleaning, and errands do not count toward the test.
• Assuming the hospital's evaluation counts. It does not. Only NYIA's assessment applies the rule.
• Letting a Plan Legacy member get disenrolled. A lapsed Medicaid renewal or a voluntary disenrollment can turn a protected person into a new applicant.
• Asking a website to score the person. No one can do this from a description, including us.

Does "more than two ADLs" mean two or three?

Three or more. DOH's own comment response refers to "the requirement of three ADLs," and its report headings read "more than 2 ADLs requiring Limited Assistance or above." For the dementia rule, "more than one" means two or more.

Can I get a copy of form DOH-5821 myself?

Yes. It is a state form posted on health.ny.gov, and NYIA's site links it. A doctor (MD or DO) must have made the diagnosis, and a doctor, nurse practitioner, or physician assistant must complete the form. Bring it to the nurse's visit or fax it to NYIA ahead of time.

I was getting home care before September 2025. Will I be cut off?

DOH says people with Legacy Status are not held to the new test at their reassessments. The risk is losing that status through a full disenrollment from MLTC. Keep the Medicaid case active and ask the plan to confirm your Legacy status in writing.

Does the rule apply to PACE?

No. MLTC Policy 25.04 says the new criteria do not apply to PACE enrollment. PACE has its own requirements, including a nursing home level of care and age 55 or older.

Who scores the test?

The New York Independent Assessor Program, during the Community Health Assessment. Plans, agencies, hospitals, and websites do not.