New Minimum Needs Requirements for Personal Care Services (PCS), Consumer Directed Personal Assistance Services (CDPAS) and Managed Long Term Care (MLTC) Eligibility

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Date of Issuance: June 30, 2025
Effective Date: September 1, 2025

To: Medicaid Managed Care Plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs)

From: Office of Health Insurance Programs, Division of Health Plan Contracting and Oversight

Re: September 1, 2025, New Minimum Needs Requirements for Personal Care Services (PCS), Consumer Directed Personal Assistance Services (CDPAS) and Managed Long Term Care (MLTC) Eligibility


Purpose: This guidance provides notification of changes to the eligibility requirements for Medicaid Managed Care (MMC) members in MMC plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs), collectively referred to in this document as MMC plans. This policy applies to members seeking Personal Care Services (PCS), Consumer Directed Personal Assistance Services (CDPAS) or looking to transfer to a Managed Long Term Care (MLTC) plan on or after September 1, 2025 .

Background: This change is the result of statutory amendments included in Chapter 56 of the Laws of 2020 and updates to accompanying regulations at 18 NYCRR §§ 505.14 and 505.28 finalized and posted in the September 8, 2021, New York State (NYS) Register with a November 8, 2021, effective date.

Chapter 56 of the Laws of 2020 amended the Social Services Law §§ 365-a and 365-f, and Public Health Law § 4403-f to change the eligibility criteria for Medicaid members initially seeking PCS or CDPAS and for individuals initially seeking enrollment into an MLTC plan. These statutes and updates to the accompanying regulations at 18 NYCRR §§ 505.14 and 505.28 establish the Minimum Needs Requirements with regard to activities of daily living (ADL).

This guidance should be read alongside all previous guidance posted here and where they differ, this guidance supersedes the previous guidance.

MMC plans will continue conducting reassessment Community Health Assessments (CHAs) to reauthorize PCS/CDPAS for all enrolled members. The reassessment process continues to be initiated with a completed Physician's Order to the MMC plan. Non-dual MMC members receiving PCS/CDPAS and voluntarily seeking a transfer into an MLTC plan still need a New York Independent Assessor Program (NYIAP) assessment to determine eligibility. Services covered through New York's 1915(c) Waivers, including the Nursing Home Transition and Diversion (NHTD), Traumatic Brain Injury (TBI), and the Office for People with Developmental Disabilities (OPWDD) Comprehensive Waiver do not require a NYIAP CHA to determine waiver eligibility.

Until further notice, the MMC plan will continue to perform initial assessments and reassessments for pediatric cases (children aged 0-17 years) to authorize PCS/CDPAS.

The Minimum Needs Requirements, as defined in the Definitions section, apply to all individuals seeking an initial assessment for PCS or CDPAS beginning on September 1, 2025. The Minimum Needs Requirements will also apply to their subsequent reassessments. Individuals authorized for PCS or CDPAS before September 1, 2025, will be granted Legacy Status, as defined in the Definitions section, and will not be subject to the new Minimum Needs Requirements at reassessment.

DEFINITIONS

The definitions below are intended to supplement the definitions in the April 28, 2022, guidance.

PCS/CDPAS Legacy Criteria (Legacy Criteria) - the eligibility criteria in effect before September 1, 2025.

Legacy Status - a classification of eligibility criteria that applies to an individual who was enrolled in PCS, CDPAS, or MLTC prior to September 1, 2025. The Uniform Assessment System (UAS-NY) will include an indicator for legacy status that identifies individuals that will not be assessed or reassessed using the new Minimum Needs Requirements.

Personal Care Services (PCS)/Consumer Directed Personal Assistance Services (CDPAS) Service Legacy (Service Legacy) - a status for individuals receiving or authorized for PCS or CDPAS services before September 1, 2025. Service Legacy individuals will be assessed and reassessed using PCS/CDPAS Legacy Criteria.

MLTC Plan Legacy (Plan Legacy) - a status for individuals enrolled in MLTC, including PACE, before September 1, 2025. Plan Legacy individuals will be reassessed using Legacy Criteria if they remain continuously enrolled in any MLTC pan.

PCS/CDPAS Minimum Needs Requirements (Minimum Needs) - the new eligibility criteria that requires individuals seeking initial eligibility for PCS and CDPAS be assessed as:

  • needing at least limited assistance with physical maneuvering with more than two ADLs; or
  • individuals with a Dementia or Alzheimer's diagnosis as needing at least supervision with more than one activity of daily living (ADL)

PROGRAM CHANGES

The initial assessment completed by NYIAP is the first step in determining eligibility for PCS/CDPAS or MLTC enrollment. Upon completion of the assessment, NYIAP will send a notice to the member explaining next steps, including whether they may be eligible for MLTC plan enrollment (in which case they should contact NYIAP), or to contact their MMC plan to complete the care planning and service authorization process if they are eligible to receive PCS/CDPAS. The notice alone does not provide complete information for service authorization.

The authorizing entity for PCS/CDPAS must use the assessment outcome in coordination with the member to create a person-centered service plan (PCSP) and plan of care (POC) that ensures the health and safety of the individual while living in the community.

For members who have an expedited request for PCS/CDPAS, the MMC plan remains responsible to coordinate with NYIAP to ensure an expedited process.

Members who are eligible to join an MLTC plan on a voluntary basis have the option to be authorized by the MMC plan to receive PCS/CDPAS.

A. Changes to Eligibility Requirements

Before implementation of the Minimum Needs Requirements, authorization for PCS/CDPAS required members to need assistance with one or more personal care services, home health aide services or skilled nursing tasks.

Effective September 1, 2025, members will be required to meet the Minimum Needs Requirements at initial assessments and their subsequent reassessments. These Minimum Needs Requirements are:

PCS/CDPAS will be 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.
B. Documentation of Alzheimer's Disease or Dementia

Individuals that are being assessed for PCS/CDPAS with an Alzheimer's or Dementia diagnosis under the Minimum Needs Requirements must provide proof of a diagnosis of Alzheimer's disease or Dementia during the assessment process.

The Alzheimer's Disease or Dementia Form (DOH-5821) must be completed with the individual's name, date of birth, diagnosis(es), diagnosis ICD-10 code(s), practitioner name, and practitioner license number. The information in this form can be completed by the licensed health care professionals listed on the form. However, the diagnosis must be made by a physician (M.D. or D.O.) with the knowledge and expertise to confirm a diagnosis of Dementia or Alzheimer's. The physician does not need to be a NYS Medicaid Provider.

Note: Documentation for Alzheimer's disease or Dementia is required at each assessment where the condition is present unless otherwise directed by the Department.

A copy of Alzheimer's Disease or Dementia Form (DOH-5821) must be retained in the member's file. The MMC plan must also document the date of documentation of Alzheimer's or Dementia diagnosis in the individual's case notes and the UAS-NY "Section H: Disease Diagnoses".

LEGACY STATUS

Legacy Status will be tracked in the UAS-NY. The Plan will be responsible for adding Service Legacy for certain individuals as detailed below . Individuals with Legacy Status will not have to meet the Minimum Need Requirements. They will be assessed and reassessed under the Legacy Criteria.

A. Determination of Legacy Status

Individuals will be granted Legacy Status as follows:

  1. Assessed and authorized for PCS/CDPAS: Individuals that are authorized for services prior to September 1, 2025, will be granted Service Legacy status.
  2. Assessed but not yet authorized for PCS/CDPAS: Individuals with a valid assessment completed after August 31, 2024, and before September 1, 2025, but not yet authorized for PCS/CDPAS through the Plan will be granted Service Legacy status, if authorized within one year of that assessment.
  3. Assessment scheduled but not yet authorized for PCS/CDPAS: Individuals with an initial assessment scheduled before September 1, 2025, whose appointment is rescheduled through no fault of their own to after September 1, 2025, will be assessed with the Legacy Criteria and granted Service Legacy status if they are authorized for PCS/CDPAS.

    Note : The rescheduling must be done before the date of the initial scheduled appointment.
B. Required Actions During Assessments and Reassessments

Documentation of Legacy Status will occur through a combination of data loaded by the Department and UAS-NY documentation by the Plan. The Legacy Status will determine whether the Plan uses the Legacy Criteria or the Minimum Needs Requirements to assess an individual for service eligibility.

Before implementation, the Department will load data to the UAS-NY to capture the Plan and Service Legacy status. Some discrepancies may occur because of a loading lag between August 1, 2025, and September 7, 2025. The Plan must track new authorizations and end of authorizations in the month of August until the data load is completed to manually update the UAS-NY, unless otherwise directed by the Department. The Plan must verify the Legacy Status of the member at the time of each assessment or reassessment and note when an individual has Legacy Status in the MMC's case notes and in the UAS-NY.

  1. Assessed and authorized for PCS/CDPAS: the MMC plan may need to manually update the Service Legacy status for individuals if changes to their PCS/CDPAS authorization need to be made during system updates because of the timing of data loaded into the UAS-NY.
  2. Assessed but not yet authorized for PCS/CDPAS: for those assessed under Legacy Criteria after September 1, 2024, and before September 1, 2025, who have not yet started services, the Plan must update their Service Legacy status if the PCS/CDPAS authorization happens within one year of the date of the finalized assessment. If services are not authorized, the individual should be referred back to NYIAP for a new assessment.
  3. Assessment scheduled but not yet authorized for PCS/CDPAS: The MMC must manually update the Service Legacy status for individuals who are assessed on or after September 1, 2025, under Legacy Criteria due to scheduling.
C. MLTC Plan Legacy

There is an additional category of MLTC Plan Legacy for those enrolled in an MLTC Plan. The MLTC Plan Legacy Status indicator in the UAS-NY identifies individuals that were assessed to be MLTC eligible prior to September 1, 2025. These individuals will not be assessed using the new eligibility criteria if they remain continuously enrolled in MLTC. Certain individuals will be granted MLTC Plan Legacy Status by their Plan. The MMC plan will not be responsible for maintaining MLTC Plan Legacy Status.

D. CHA Variance Requests

When using a CHA completed by NYIAP, inaccuracies maybe identified that are either clinical, such as judgement of the individual's presentation at the time of separate appointments, or factual. For more information on the CHA Variance process, please refer to MMC Guidance issued April 28, 2022. Plan Legacy will be based on the date of finalization of the NYIAP assessment that was performed before the CHA Variance request. If a NYIAP Variance Process results in NYIAP conducting another initial assessment, the Legacy Criteria will be used if the original assessment date was before the transition. The Practitioner Order cannot be disputed as part of the Variance submitted by the District or Managed Care Plan.

SYSTEM CHANGES

A. UAS-NY

The UAS-NY 1.18 Release in October 2024 includes the new Minimum Needs Requirements. This Release included Plan and Service Legacy status in the Assessment Outcomes and LTC Legacy Status fields. The UAS-NY will release the Legacy Node after September 1, 2025, that will allow viewing and editing of the Legacy Status information.

Individuals that are authorized for PCS/CDPAS or continuously enrolled in an MLTC plan as of August 1, 2025, will have Legacy Status applied, which will be viewable in the Assessment Outcomes and LTC Legacy Status fields. The Department will perform a one-time update of MLTC Plan and Service Legacy fields for individuals that have Legacy Status prior to implementation. Discrepancies may happen because of timing between the one-time update and the date of implementation on September 1, 2025. The Plan must track new authorizations and end of authorizations in the months of August and September until the time of the data load is completed and manually update the UAS. The viewing and editing of Legacy Status mentioned above will not be visible until the one-time update is complete after September 1, 2025. The Plan is expected to continue to track new authorizations and manually update Service Legacy up to one year after implementation or as directed by The Department.

B. UAS-NY Changes

The UAS-NY will show information in the CHA Assessment Outcomes and LTC Legacy Status to reflect the MLTC Plan and Service Legacy status(es) of individuals. Authorized users will be able to Edit Service Legacy by selecting this option in UAS.

NOTE: MMC plan users are not responsible for entering or maintaining MLTC Plan Legacy changes.

1. Service Legacy Fields in UAS-NY
When "No" is preselected in the PCS/CDPAS Service Legacy Status field, the individual does not have Legacy Status. The PCS/CDPAS Service Legacy Status field will be "Yes" when it was either added at implementation or afterward as described in this policy.

The MMC plan must update Service Legacy based on the tracking performed to identify new authorizations in the month of August up to the time of the data load to manually update the UAS-NY.

After Implementation: For individuals that had a valid assessment dated August 1, 2024 through August 31, 2025, the Plan should add PCS/CDPAS Service Legacy if the individual is authorized for services within one year of the date of their assessment. When Service Legacy is not already reflected, Service Legacy will be added by selecting "Yes" for the PCS/CDPAS Service Legacy Status field and entering the PCS/CDPAS Service Legacy Status Start Date which should correlate to the new authorization date.

2. UAS-NY Roles Impacted
All Long Term Care (LTC) user roles will have Read Only access to view the Legacy information. Authorized users will be able to edit the Legacy fields in the UAS-NY when adding or removing Legacy status. These include LTC-02, 15, 45, and 50 user roles.

C. UAS-NY Training

Legacy Status training in the UAS-NY will be available to all Long Term Care and Long Term Care Independent Assessor users prior to September 1, 2025. The training will go live in the weeks prior to September 1, 2025. This training will include how to locate and understand the LTC Legacy Status node, Legacy Status in the Assessment Outcomes node, and provide descriptions of the fields within the UAS-NY. This training will remain recommended until early September 2025, when the training will become required. Required dates are staggered for LTC and LTC-IA user roles.

Specific training for those with Edit Access will also be available prior to September 1, 2025 for roles: LTC-02, 15, 45, and 50. This course covers step-by-step procedure information to update Legacy Status using the most common scenarios users will encounter.

REPORTING

Additional Data Request for MMC Plan Members
The Department will request data for all MMC plan members authorized for services in order to allow the State to preload information into the UAS-NY.

NYIAP Reports
NYIAP will make Legacy Status Reports available to the MMC plans via the Department approved secure file transfer platform. The reports for MMC plans are:

  • Scheduled Appointments Next 30 Days – Provided there is an enrollment record in the UAS-NY, this weekly report supplies the MMC plan with a list of members that are scheduled to be reassessed within the next 30 days. The report includes the appointment date, appointment type, and appointment reason.
  • CHA Appointment Outcomes* – This daily report lists the assessment status outcome for the member (qualified or unqualified) and the reason for the determination.
  • Practitioner Order (PO) Appointment Outcomes* – This daily report indicates if the member's condition is stable to receive PCS/CDPAS in the home.

    * The MMC plan is to use the information in these two reports to look up the member in the UAS-NY and review the CHA and PO to determine the need for and level of services, create a POC, authorize services, and create an enrollment record in the UAS- NY.
  • Variance Report – This weekly report lists the members who have requested a variance and includes the reason for and the status of the request. The MMC plan is expected to review this report and consider the recommendations prior to finalizing the POC and authorizing services.
  • IRP Requests – This weekly report lists the members for whom a secondary medical review was required and includes the reason for and the status of the request. The MMC plan is expected to review this report and consider the recommendations prior to finalizing the POC and authorizing services.

To request secure file transfer access to the reports, email NYIAPHPA@maximus.com and include the following in the request:

  • Member Name
  • Email Address
  • County
  • Name of each report as outlined above