Minimum Needs: the test New York applies before Medicaid home care or MLTC

The test in one table

The Department of Health states the rule two ways, one for most adults and one for people with a confirmed dementia or Alzheimer’s diagnosis. “ADL” means activity of daily living. For MLTC plans there is a second condition that already existed: you must need community-based long term care for more than 120 days.

“More than two” means three. The Department’s own comment response calls it “the requirement of three ADLs,” and its report columns read “more than 2 ADLs requiring Limited Assistance or above.” “More than one” means two.

What “limited assistance” and “supervision” mean comes from the State’s assessment tool. In DOH training language, supervision is “oversight/cuing required” and limited assistance is “help required on some occasions.” So for most adults, another person’s hands have to be needed at least some of the time for three activities. Reminding from across the room does not count unless the dementia form is in the assessor’s hands. DOH has not published a consumer definition of “physical maneuvering.” The longer read on the wording is in the Minimum Needs Requirements, explained.

Which activities count

The Department’s outcome-notice FAQ lists the activities of daily living in everyday words:

• 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

Cooking, cleaning, laundry, shopping, managing money, and getting to appointments are real needs, but they are not on this list. Neither is managing medications. A person whose only needs are on that second list does not meet the test. A person who does meet the test can still get help with those things as part of the care plan.

Who the test applies to

The Department’s consumer page draws the lines this way:

• Adults 21 and older newly seeking Medicaid personal care or consumer directed personal assistance.
• Adults 18 and older newly seeking to enroll in an MLTC partial capitation plan or a Medicaid Advantage Plus plan.
• At the first assessment and at every reassessment after it, for anyone first assessed on or after September 1, 2025.

Who it does not apply to:

• PACE enrollment. MLTC Policy 25.04 says the new criteria “do not apply to enrollment in Programs of All-Inclusive Care for the Elderly (PACE) plans.” PACE keeps its own rules: age 55 or older, a nursing home level of care, and more than 120 days of need.
• People with Legacy Status, explained next.
• Children under 18. DOH says the process for children “has not changed and is not impacted by” the new requirements.
• Certain waiver programs. The Nursing Home Transition and Diversion, Traumatic Brain Injury, and OPWDD waivers do not use the NYIA assessment to decide waiver eligibility.

Legacy or new: which rules apply to you

DOH calls the old rules the “Legacy Criteria.” Under them, needing help with one personal care task was enough. Whether you are held to the old rules or the new test depends on your status on September 1, 2025. Find your line:

• Services were authorized before September 1, 2025. You have Service Legacy. DOH’s Medicaid Update says you keep it even if services stop and you come back later.
• You were enrolled in an MLTC plan, including PACE, before September 1, 2025, and have stayed enrolled without a break. You have Plan Legacy. Switching from one MLTC plan to another “with no break in enrollment” keeps it.
• You left MLTC entirely after September 1, 2025. Plan Legacy is gone. To re-enroll you must meet the new test. Service Legacy for personal care or CDPAP is not affected by an MLTC disenrollment.
• You were assessed between August 31, 2024 and September 1, 2025 but not yet authorized or enrolled. You keep the old rules if services are authorized, or MLTC enrollment happens, within one year of that assessment.
• Your appointment was scheduled before September 1, 2025 and moved past that date through no fault of your own. DOH says the Legacy Criteria still apply. The rescheduling has to have happened before the original appointment date.
• None of the above. You are a new applicant, and the table at the top of this page is your test.

Legacy members with dementia do not need to file DOH-5821. If you believe you have Legacy status, say so to NYIA and to the plan, and ask the plan to confirm it in writing. Keep the dated letters.

Reassessments and MLTC Policy 26.01

The test is not a one-time gate. It applies again at each reassessment for anyone without Legacy status. NYIA does not do reassessments (DOH’s NYIA page says they were paused in January 2024 with no new date). Your MLTC plan, your Medicaid managed care plan, or the local district does them, and DOH requires the plan to check your Legacy status in the State’s assessment system first.

On April 7, 2026 the Department issued MLTC Policy 26.01, effective June 1, 2026. It rewrote the rules for plan-initiated (involuntary) disenrollment to fit the Minimum Needs Requirements. What it means for members:

• Without Plan Legacy: if a reassessment finds you no longer meet the Minimum Needs test, the plan must start the involuntary disenrollment process within five business days of that assessment. The outcome listed in the policy is disenrollment to regular (fee-for-service) Medicaid. If you have a dementia diagnosis, the plan’s package must include your DOH-5821.
• With Plan Legacy: “no longer meets Minimum Needs” is not a disenrollment reason for you. You are reassessed under the Legacy Criteria. A Plan Legacy member who is moved to another MLTC plan through an involuntary disenrollment keeps Plan Legacy.
• Everyone, Legacy or not: other reasons still apply, such as not receiving at least one long-term service in the previous month (housekeeping-only services and social adult day care do not count), refusing or not being reachable for the required reassessment, or being out of the plan’s service area for more than 30 days.
• Your rights: New York Medicaid Choice, not the plan, sends the disenrollment confirmation notice. The policy says fair hearing rights, including aid to continue, apply to that notice. The policy also says a plan may never pressure or coerce a member into agreeing to disenroll, and that a member who fixes the problem before the effective date, for example by completing the missed reassessment, can stay enrolled.

Appeals are their own subject and this page stops here. The plan’s notice and the New York Medicaid Choice notice each explain the deadlines that apply to you.

What to do next

1. Make sure Medicaid is active. NYIA will not schedule without a Medicaid number. In New York City the Medicaid Helpline is 1-888-692-6116; elsewhere, call your county Department of Social Services. Not on Medicaid yet? Start with where Medicaid home care starts.
2. If there is a dementia or Alzheimer’s diagnosis, get form DOH-5821 signed first. A doctor (MD or DO) must have made the diagnosis; a doctor, nurse practitioner, or physician assistant can fill out the form. The doctor does not have to take Medicaid. Fax it to NYIA at 917-228-8601 before the visit, or hand it to the nurse.
3. Schedule the assessment. NYIA at 1-855-222-8350 (TTY 1-888-329-1541), Mon–Fri, 8:30 a.m.–8:00 p.m.; Sat, 10:00 a.m.–6:00 p.m.. Ask for an interpreter when you book, not on the day. What to have in the room is in the NYIA assessment prep checklist.
4. Describe a real day, bad days included. Say which activities need another person’s hands and how often. Do not rehearse an answer; assessors are trained to notice.
5. Read the letter and watch the 60 days. The notice says whether you met the test, whether you are medically stable for home care, and whether you may enroll in an MLTC plan. If you disagree, you have 60 days from the notice to ask for a conference, a fair hearing, or both. If you met the test, the next stop is the plan, described in MLTC enrollment steps after your eligibility letter.

Mistakes that cost people the test

• Treating a hospital or agency evaluation as the assessment. Only NYIA’s nurse visit applies the rule. A discharge planner’s opinion is useful information, not a score.
• Bringing the diagnosis in the chart instead of on the form. A hospital record that says “dementia” does not unlock the two-activity rule. DOH-5821 does.
• Leaving MLTC “for a while.” A voluntary disenrollment, or a Medicaid case that lapses, ends Plan Legacy. Coming back means passing the new test.
• Skipping the reassessment call. Under Policy 26.01 a member who cannot be reached for the required reassessment can be disenrolled after ten documented attempts over 30 days, including two home visits. Answer the plan’s calls and letters.
• Asking a website to score the person. No one can do it from a description, including us.

Free help

NY Connects at 1-800-342-9871 (Relay 7-1-1) is the State’s free line for long-term services and supports at any age, on Medicaid or not. HIICAP at 1-800-701-0501 handles the Medicare side for free. Neither can apply the test or promise hours, and neither sells anything. The full who-does-what list is on who to call for home care in New York.