As If the 90’s Never Left: Medicaid in 2026

Generation X was conditioned to believe that its cultural footprint would only leave the faintest impression. It took a few visits to the mall with my teenage daughter to dispel that belief.

A Nirvana T-shirt hung next to an Oasis T-shirt, which hung next to a Sublime T-shirt. Oversized, baggy sweatshirts dominated the clothing racks. These were not artifacts from some 50-year-old’s closet. This IS the style.

There is something to be said about the iconography and styles of your parents’ generation – familiar, but just out of reach. We were no strangers to Elvis, Marilyn, and Sinatra. The assumption was that the past was a little more fun and little less complicated.

I did not expect this 90’s mini renaissance to extend to Medicaid, but here we are – and not in a good way. When I began my elder law career as young law clerk in New York City, the majority of Medicaid applications I handled were nursing home or institutional. There was also a special home care waiver known as the Lombardi Program which was called the “nursing home without walls.” It allowed a home care recipient to receive nursing home quality care in the home.

Lombardi eligibility mirrored nursing home Medicaid eligibility for many years (a three-year lookback then five-year lookback, before finally removing the lookback in 2007). Lombardi recipients during those lookback years were few. There was a true binary Medicaid system in place, with the seriously ill in nursing homes and moderately ill receiving community-based home care.

Home care options for seriously ill individuals and the assisted living Medicaid program were limited. 

The last two decades saw an expansion of home care options including the Nursing Home Transition & Diversion Program, which emerged out of a flourishing Lombardi program during the current managed long-term care era, offering nursing home quality care in the home but with community budgeting and no lookback. Thousands of additional NHTD recipients plus a massive increase in assisted living Medicaid beds offered more flexibility to those requiring care.

Now that expansion is being curtailed. A cap on NHTD waivers is in effect. Seriously ill New Yorkers have to either direct placement to a nursing home or hope that the managed long-term care agencies award substantially more home care hours than have been awarded in recent years.

This also changes the nature of the Medicaid Assisted Living Program. Without a viable NHTD program in place, assisted living residents who experience sharp health declines will only have nursing homes as their next destination instead of a home care option. 

The removal of the best home care options will force New York families to start planning earlier. Community-based home care does not have a lookback resulting in a penalty period. Assets can be transferred and eligibility obtained quickly during a healthcare crisis. 

The immediacy of this eligibility framework worked great when the care matched the illness. Now, the care may not fit the needs of the ill individual. Only a nursing home would provide the necessary support, but there are barriers to eligibility. Nursing home Medicaid’s five-year lookback is an impediment where there is no spouse or disabled child to provide exempt transfers or no adult child residing in the ill individual’s residence.

With home care options in a state of flux, gauging one’s Medicaid nursing home rligibility status now, before an illness strikes, is an intelligent way to plan for worst-case scenarios. 

Alan D. Feller, Esq., is managing partner of The Feller Group, located at 572 Route 6, Suite 103, Mahopac. He can be reached at alandfeller@thefellergroup.com.