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Why Doesn’t Medicare Cover CDPAP?

As aging populations and individuals with disabilities seek independence and personalized care, programs like New York State’s Consumer Directed Personal Assistance Program (CDPAP) have emerged to meet this growing demand for self-directed care.

The CDPA program allows recipients to select, train, and manage their caregivers, who assist with daily activities right in the comfort of the recipient’s own home. This program offers autonomy and flexibility, designed to empower individuals living with chronic medical conditions or physical disabilities and give them greater control over their care.

As a Medicaid initiative, CDPAP provides support through financial reimbursement, ensuring the chosen caregivers of qualified Medicaid consumers get paid for their time and effort.

But what if you have Medicare? Does Medicare cover CDPAP?

The quick answer? No. Unfortunately, simply having Medicare is not enough to qualify for participation in the program.

Despite the fact that Medicaid and Medicare are both government-funded health plans, there are major differences in the qualifications and coverage of each. Since CDPAP is a Medicaid-based program, enrollment in Medicaid is required.

Confused? Keep reading to learn more about why Medicare doesn’t cover CDPAP and the different options you have when it comes to getting support for your home care services.

What Is CDPAP?

To help you understand why Medicare doesn’t cover CDPAP, let’s break down what the Consumer Directed Personal Assistance Program is.

Rather than relying on a rotating staff of caregivers assigned by an agency, CDPAP allows individuals to choose their own caregivers. This makes it possible for recipients to receive care from someone they trust and feel comfortable with, such as a family member or friend.

Recipients also have greater control over how their care is delivered. Under the CDPA program, caregivers are considered employees of the recipient rather than employees of an agency. This means that recipients are able to hire, train, and schedule their caregivers, as well as manage their own care plan.

Why Medicaid Covers CDPAP

Medicaid is a joint federal and state program designed to provide healthcare coverage for low-income individuals, including those with disabilities or chronic conditions who require long-term care services. It makes sense, then, for CDPAP to be a Medicaid-funded program since it serves individuals who need regular care and assistance.

By offering financial support, the CDPA program makes long-term care services accessible to low-income individuals and provides much-deserved compensation to those already assisting and caring for their loved ones.

Does Medicare Cover CDPAP?

Medicare is a federal health insurance program primarily for people aged 65 and older, as well as certain younger individuals with disabilities. While it offers coverage for many healthcare services, it does have its limitations, particularly regarding long-term care.

Medicare is designed primarily to cover short-term, medically necessary care and consists of different “parts.” Parts A and B are government-funded:

  • Part A (hospital insurance) covers inpatient care at hospitals, hospice, skilled nursing facilities, as well as some outpatient home health care. It is free if you worked and paid Medicare taxes for at least 10 years.
  • Part B (medical insurance) covers doctor services, outpatient care, medical equipment, home health care, and some preventative services. It costs a monthly premium for most people.

Parts C and D are run by private companies and cost more:

  • Part C (Medicare Advantage) bundles several coverage types and may also include vision, hearing, and dental insurance.
  • Part D helps cover prescription drug costs.

As touched on in Parts A and B, home health care services are covered by Medicare under certain conditions. Namely, Medicare covers medically necessary care provided by healthcare professionals, such as nurses and therapists. This may include intermittent skilled nursing care, physical therapy, occupational therapy, and speech-language pathology services.

Unfortunately, Medicare does not cover custodial care or long-term assistance with activities of daily living such as bathing, dressing, or feeding. That’s why, for those who require ongoing personal assistance, Medicaid is the primary source of financial support via CDPAP.

How Can I Get In-Home Care Services?

Having Medicare doesn’t necessarily mean you can’t get the in-home care you need. Here are some solutions to consider:

1. Apply for Medicaid

Because it’s the primary funding source of the CDPA program, you’ll have to apply for Medicaid if you want support through the program. Luckily, you can enroll in both Medicare and Medicaid simultaneously. In many cases, there’s no cost involved if your income falls within Medicaid’s qualifying income level.

2. “Spend Down” To Qualify for Medicaid

If your income exceeds the Medicaid income limit, you might opt for a Medicaid spend down. This involves paying the difference between your income and the qualifying limit to gain access to Medicaid coverage and programs, including CDPAP.

3. Enroll in a Pooled-Income Trust

Another option for those earning above Medicaid’s income limit is enrolling in a pooled-income trust. Managed by non-profit organizations, these trusts function as managed bank accounts where you deposit your surplus income in order to meet Medicaid’s income limit. The organization then handles bill payments and reimburses you for out-of-pocket expenses.

4. Pay Out of Pocket

If you prefer not to involve others in managing your finances, you can pay for services yourself. While this may require a significant financial commitment, this option offers you the freedom to choose your caregiver and manage your care plan, similar to the choices provided by CDPAP.

Ultimately, while Medicare may not cover CDPAP, there are other options to consider. Understanding your eligibility and exploring all available options can help you access the care and support you need to remain independent and comfortable in your own home.

Navigate CDPAP With CDChoices

In short, Medicaid funds CDPAP while Medicare does not. This is because Medicare primarily focuses on medical services provided by doctors, hospitals, and other healthcare providers rather than long-term personal care services provided through the CDPA program.

If you’re unsure about your eligibility for Medicaid or have questions about the Consumer Directed Personal Assistance Program, feel free to reach out to us here at CDChoices. As a fiscal intermediary dedicated to helping you manage your CDPA program, we’ll be happy to help you navigate the process.

Learn more about how we can assist you by contacting us today.

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