The Complete Guide to Medicare and CDPAP in New York for 2026

If you or someone you love needs help at home in New York, two programs can make a real difference: Medicare and CDPAP. Medicare Part A and Part B together cover hospital stays, doctor visits, and short-term skilled nursing - but they do not cover the long-term personal care that most people actually need day to day. That is where CDPAP comes in. The Consumer Directed Personal Assistance Program lets you choose your own caregiver, including a family member, and have Medicaid pay them $18.10 to $23.81 per hour to help you at home.

This guide covers how both programs work, what they pay, who qualifies, how to appeal when claims get denied, and when to bring in a patient advocate.

Here is the reality: navigating Medicare, Medicaid, and home care in New York is a full-time job that nobody trained you for. You are dealing with different parts of Medicare that cover different things, a CDPAP program that most people have never heard of, insurance denials that feel like dead ends, and medical bills that look like they were written in code.

We hear from patients and families every week who are overwhelmed by the system. They did not know their daughter could get paid to help them at home. They did not know they could appeal a Medicare denial and win. They did not know a patient advocate could do most of this work for them at no cost.

Quick Reference: Medicare and CDPAP at a Glance

Part 1: Understanding Medicare - What Part A and Part B Actually Cover

Medicare can seem complicated at first glance, but the core structure is simpler than you might think. The program has two foundational pieces that every beneficiary should know. Part A and Part B together make up what is called Original Medicare, and they handle different types of care.

What Does Medicare Part A Cover?

Think of Part A as the side of Medicare that handles the big stuff. If you end up in the hospital, need skilled nursing after a fall, or qualify for hospice care, Part A is what pays for it. Most people who worked at least 10 years pay nothing for Part A coverage.

Part A covers four main categories:

Inpatient hospital stays. When you are admitted to a hospital as an inpatient, Part A covers your room, meals, nursing care, medications given during your stay, lab tests, and surgeries. For 2026, you pay the $1,676 deductible once per benefit period for days 1 through 60, then $0. Days 61 through 90 cost $419 per day. Days 91 and beyond use your lifetime reserve days at $838 per day - and you only get 60 of those total, ever.

Skilled nursing facility care. If you need skilled nursing care after a qualifying hospital stay of at least 3 days, Part A covers up to 100 days per benefit period. Days 1 through 20 cost $0 after the deductible. Days 21 through 100 cost $209.50 per day in 2026. After day 100, you pay the full cost yourself. This is not the same as long-term nursing home care, which Medicare does not cover.

Hospice care. If you have a terminal illness and choose comfort care over curative treatment, Part A covers hospice - including nursing care, pain management, counseling, and medication related to your diagnosis. You pay $0 for most hospice services.

Home health services. Part A covers home health care when you are homebound and need skilled nursing or therapy on a part-time basis. This can include a visiting nurse, physical therapy, occupational therapy, and some medical supplies. You pay $0 for covered home health services.

What Does Medicare Part B Cover?

Part B handles everything that happens outside of a hospital admission - your doctor visits, lab tests, outpatient procedures, and preventive screenings. For most people over 65, this is where the majority of their medical spending occurs.

Doctor and outpatient services. Part B covers visits to your doctor's office, specialist appointments, outpatient surgeries, diagnostic tests like X-rays and bloodwork, mental health services, and second opinions before surgery. After you meet your annual $257 deductible, you typically pay 20% of the Medicare-approved amount.

Preventive services. One of the biggest benefits of Part B is that many preventive services are covered at no cost to you, with no deductible and no coinsurance. These include your annual wellness visit, flu and COVID-19 shots, mammograms, colonoscopies, cardiovascular screenings, diabetes screenings, depression screenings, and bone density tests.

Durable medical equipment. Part B covers wheelchairs, walkers, hospital beds for home use, oxygen equipment, and blood sugar monitors. You pay 20% of the Medicare-approved amount after your deductible.

Ambulance services. Part B covers ambulance transportation when other transportation would endanger your health. You pay 20% coinsurance after the deductible.

2026 Cost Comparison: Part A vs Part B

New for 2026: there is now a $2,700 cap on Part B out-of-pocket spending. Before this year, there was no limit at all. If you need a lot of outpatient care, this cap could save you thousands of dollars.

Part B Income-Based Premiums (IRMAA)

Higher-income beneficiaries pay a surcharge on Part B premiums called IRMAA (Income-Related Monthly Adjustment Amount). The threshold starts at $106,000 for individuals and $212,000 for couples. This adjustment Amount.

There is good news if your financial situation has changed. If you recently retired, lost a spouse, or experienced another qualifying life event, Social Security lets you request a reassessment of your IRMAA. You file what is called a life-changing event form with Social Security.

When Do You Enroll in Part A and Part B?

You get a 7-month window to sign up for Medicare around your 65th birthday - starting 3 months before and ending 3 months after. If you miss this window and do not have employer coverage, you may face a permanent late penalty of 10% added to your Part B premium for every year you waited. If you are already receiving Social Security benefits when you turn 65, you are enrolled automatically.

If you delayed Medicare because you had coverage through an employer, you get a Special Enrollment Period - 8 months after that employer coverage ends to sign up without a penalty.

Late enrollment penalties are serious. Your Part B premium goes up 10% for every full 12-month period you could have had Part B but did not sign up. That penalty is permanent. If you waited 3 years, that is a 30% surcharge on your Part B premium for the rest of your life.

What Medicare Does Not Cover

Even with both Part A and Part B, Original Medicare has notable gaps. It does not cover prescription drugs (you need a separate Part D plan), dental care, vision care, hearing aids, long-term custodial care in a nursing home, or care received outside the United States.

Here is the big one for this guide: Medicare does not cover long-term personal care at home. If you need someone to help you bathe, get dressed, cook meals, and manage daily life on an ongoing basis, Medicare will not pay for it. That is where Medicaid and CDPAP step in.

Read the complete breakdown: Medicare Part A vs Part B - What Each Covers

Part 2: What Is CDPAP and Who Qualifies in New York?

New York has a program called CDPAP - the Consumer Directed Personal Assistance Program - that works very differently from regular home care. Instead of an agency sending a stranger to your home, you pick someone you already know and trust. That person gets hired as your caregiver and Medicaid pays their wages.

Many families tell us the same thing: they had no idea a program like this existed. Their daughter was already helping Mom get dressed every morning, or their son was driving Dad to every doctor appointment - but nobody was getting paid for it. CDPAP changes that.

The eligibility rules are straightforward: you need to be on Medicaid, a doctor needs to confirm you need help at home, and you (or a family member acting on your behalf) need to be able to direct your own care. There is no age requirement in either direction.

How Does CDPAP Work?

The Consumer Directed Personal Assistance Program turns the traditional home care model on its head. Rather than an agency assigning you a stranger, CDPAP puts you in the driver's seat.

You choose who helps you, train them on your specific needs, and set your own schedule. This approach, called "self-direction," it means you handle four things: recruiting your caregiver, hiring them, training them on what you need, and supervising the care. If something is not working out, you also have the right to let that caregiver go and find a new one.

A fiscal intermediary handles the paperwork side. The FI (fiscal intermediary - the company that handles your caregiver's payroll and paperwork) processes payroll, manages taxes, and handles workers' compensation insurance for your caregiver. Think of them as the behind-the-scenes employer on paper, while you stay in charge of the actual care.

Can Family Members Get Paid as CDPAP Caregivers?

Absolutely - and this is what makes CDPAP unique among New York's home care programs. You can hire a spouse, adult child, parent, sibling, or close friend as your paid caregiver. Many families find this arrangement far more comfortable than having a stranger in the home, and it keeps care dollars within the family. For the full list of who qualifies, see our CDPAP eligibility guide.

No medical certification or training is required. You teach your caregiver what you need - whether that means helping with bathing, preparing meals, or even administering medication. This flexibility is unique to CDPAP.

Who Qualifies for CDPAP?

To be eligible for CDPAP, you need to meet three requirements:

1. You must be eligible for Medicaid. CDPAP is a Medicaid-funded program. If you already have Medicaid, you have cleared the biggest hurdle. If you have both Medicare and Medicaid (called "dual eligibility"), you qualify too. Many seniors 65 and older fall into this category.
2. You must need home care services. A medical professional has to confirm that you need help with activities of daily living - things like bathing, getting dressed, eating, or moving around your home. You may also qualify if you need skilled nursing tasks performed at home.
3. You must be able to self-direct your care. This means you can make decisions about your own care, or you have a designated representative - often an adult child or other family member - who can do it for you.

Adults and children of any age can qualify. Parents often apply on behalf of children with disabilities, and adult children frequently apply on behalf of aging parents who need a designated representative to manage the program.

What Are the Medicaid Income Limits for CDPAP in 2026?

If your income is slightly above the limit, you may still qualify through New York's Medicaid Spend-Down program, which works like a deductible - you pay the gap between your income and the threshold, and Medicaid covers the rest. A SHIP counselor can help you figure out whether this applies to your situation.

What Services Does CDPAP Cover?

CDPAP covers a wide range of home care services. Your caregiver can help with personal care (bathing, grooming, dressing, toileting, and feeding), mobility assistance, skilled nursing tasks (medication administration, insulin injections, wound care, catheter management), meal preparation, light housekeeping, transportation to medical appointments, and errands like grocery shopping.

Something that surprises many families: under CDPAP, your caregiver can handle medical tasks like giving injections, managing a catheter, or changing wound dressings - things that would normally require a licensed nurse. Because you are directing the care yourself, these restrictions do not apply. For more detail on services, eligibility criteria, and the full application process, see our complete CDPAP eligibility guide. If you are managing a chronic condition that requires daily medical tasks at home, this flexibility can be a significant advantage.

CDPAP vs Traditional Home Care

Read the complete breakdown: What Is CDPAP and Who Qualifies in New York?

Part 3: How Much Does CDPAP Pay Caregivers in 2026?

If you are considering becoming a CDPAP caregiver for a family member or loved one, the pay is one of the first questions you will have. The good news is that CDPAP rates are consistently higher than what most home health aide agencies pay, and you do not need any formal certifications to get started.

2026 CDPAP Pay Rates by Region

CDPAP caregiver pay in New York varies by county because rates are tied to Medicaid reimbursement schedules. Here is what caregivers are earning right now:

These rates reflect 2026 figures following the New York State minimum wage increases. CDPAP rates exceed both the NYC minimum wage ($16.50/hour) and the state minimum ($15.50/hour) because Medicaid home care reimbursements include additional funding for benefits and program administration.

How Does CDPAP Pay Compare to Agency Work?

CDPAP almost always pays better than traditional home health aide positions at agencies. A certified home health aide working through an agency in New York City typically earns $16.50 to $18.00 per hour in 2026. CDPAP caregivers earn more because there is no agency middleman. The fiscal intermediary takes a smaller administrative fee than a full-service home care agency, and the rest goes directly to you.

How Does Overtime Work?

Overtime rules follow standard New York State labor law: anything over 40 hours in a week is paid at time-and-a-half. At the current NYC rate of $23.81 per hour, overtime comes to $35.72 per hour. Our CDPAP pay guide breaks down exactly how overtime, live-in rates, and regional differences affect your paycheck. For every hour past 40.

A few important details: the 40-hour threshold is per work week, not per day. Live-in caregivers who work a 24-hour shift are typically paid for 13 hours, with 11 hours designated for sleep and meals. If your work day spans more than 10 hours, even with a break in between, you may be entitled to an extra hour of pay at minimum wage (spread-of-hours pay). And overtime must be authorized by your fiscal intermediary based on the patient's approved care plan.

Do CDPAP Caregivers Get Benefits?

Benefits depend on your fiscal intermediary (FI) and how many hours you work.

Many FIs offer health insurance to caregivers who work 30 or more hours per week. All CDPAP caregivers in New York are entitled to workers' compensation coverage and are covered under New York's Paid Family Leave and disability insurance programs. Your fiscal intermediary withholds taxes from your paycheck just like any other employer, and you receive a W-2 at tax time.

If you need help understanding your benefits or managing the coordination between Medicare and Medicaid for the person you care for, a patient advocate can walk you through the specifics of your situation.

Read the complete breakdown: How Much Does CDPAP Pay Caregivers in New York (2026)?

Part 4: How to Apply for CDPAP and Become a Caregiver

For the Patient: How to Apply for CDPAP Services

The application process involves several steps and can take a few weeks from start to finish. Here is the typical path:

1. Confirm Medicaid eligibility. If you do not already have Medicaid, apply through your local Department of Social Services or online at myBenefits.ny.gov. Gather your income documentation, identification, and proof of residency.
2. Get a physician's order. Your doctor needs to write an order stating that you require home care services. This is a standard medical form - ask your primary care physician.
3. Complete an assessment. Your local Department of Social Services or your Managed Long-Term Care (MLTC) plan will schedule a home assessment. A nurse evaluator will determine what services you need and how many hours per week.
4. Get approved for CDPAP specifically. Once the assessment confirms you need home care and can self-direct (or have a representative), you will be authorized for CDPAP.
5. Choose a fiscal intermediary. You select an FI to handle payroll and administrative tasks for your caregiver. New York consolidated its fiscal intermediaries in 2023 and 2024, reducing the number of available FIs. Your MLTC plan or local social services office can provide the current approved list for your area.
6. Hire your caregiver. Once you have an FI in place, you recruit and hire your caregiver. They will need to complete onboarding paperwork through the FI, including a background check and employment forms.

The whole process typically takes 4 to 8 weeks if you already have Medicaid. If you need to apply for Medicaid first, add another 4 to 6 weeks.

For the Caregiver: How to Get Started

To qualify as a CDPAP caregiver, you must be at least 18 years old, legally authorized to work in the United States, physically able to perform the required tasks, and able to pass a background check. You will also need a brief health screening - usually a physical exam and TB test.

The enrollment process looks like this:

1. Confirm the patient's eligibility. The person you will be caring for needs active Medicaid coverage and an approved MLTC plan.
2. Complete enrollment paperwork through the FI. You will fill out employment forms (W-4, I-9), consent to a background check, and provide proof of work authorization.
3. Get your health screening. Most fiscal intermediaries require a physical exam and TB test within 12 months of starting.
4. Start providing care. Once the paperwork clears and the patient's hours are authorized, you can begin. The patient trains you on their specific needs. You log your hours on timesheets submitted to the fiscal intermediary.

From completing the enrollment paperwork to receiving your first paycheck, expect about 2 to 4 weeks. Having your documents ready - ID, work authorization, and a completed physical exam - speeds things up considerably.

How Many Hours of Care Can You Get?

There is no fixed number. Your care hours are determined by the assessment conducted by your MLTC plan or local Department of Social Services. Based on the evaluation, you may be approved for a few hours per week for light assistance, several hours per day for moderate care needs, or up to 24/7 live-in care for individuals with extensive needs.

If your condition changes - after a hospital stay or a new diagnosis, for example - you can request a reassessment to increase your hours. We recommend keeping detailed notes about what tasks you need help with before your assessment. The more specific you are, the better your chances of getting the hours that match your real needs.

How Medicare and CDPAP Work Together

Here is where people often get confused: Medicare and CDPAP are funded by different programs. Medicare (federal) covers your hospital stays and doctor visits. CDPAP is paid for by Medicaid (state). But many seniors 65 and older qualify for both - this is called "dual eligibility" - and your Medicaid side is what pays for CDPAP.

The gap is important to understand: Medicare will cover your hospital stay and your follow-up doctor visits, but it will not pay someone to help you get dressed, cook your meals, or manage your medications at home on an ongoing basis. That is exactly the gap CDPAP fills. They serve different roles in your overall care picture.

If you receive both Medicare and Medicaid, you may be enrolled in a Managed Long-Term Care (MLTC) plan. These plans bundle your benefits together, and your CDPAP services fall under the MLTC umbrella. The important thing to know is that your MLTC plan will be managed through that plan rather than directly through your county's Department of Social Services.

Not sure about your eligibility status? The quickest way to find out is to check the cards in your wallet - if you have both a Medicare card and a Medicaid card, you are dual-eligible. You can also call 1-800-MEDICARE (1-800-633-4227) to confirm.

Part 5: How to Appeal a Medicare Denial

A Medicare denial does not mean the conversation is over. In fact, the system is specifically designed to give you multiple chances to challenge a decision.

The appeals process has five levels, each reviewed by a separate entity, and the statistics strongly favor people who speak up. The numbers are in your favor. Roughly half of all first-level appeals result in the denial being overturned. Many denials get reversed simply because additional documentation was provided that was not included in the original claim.

Why Do Medicare Claims Get Denied?

The most common reasons include: Medicare decided the service was not medically necessary, the doctor's office submitted the wrong billing code, the service is not covered under your plan or you have used up your allowed benefit, the service needed prior authorization that was not obtained, you received care from an out-of-network provider (Medicare Advantage), a claim was submitted twice, or the provider did not submit the claim within Medicare's deadline.

Before filing a formal appeal, call your doctor's billing office. Some denials are caused by simple coding errors or duplicate submissions that can be corrected and resubmitted without going through the full appeals process. If that does not fix it, you have 120 days from the date on your Medicare Summary Notice to file a Level 1 appeal.

How to Read Your Denial Notice

When Medicare denies a claim, you will find the details in one of two documents.

If you have Original Medicare, look for your Medicare Summary Notice (MSN) - it arrives in the mail every quarter. If you have a Medicare Advantage plan, look for an Explanation of Benefits (EOB) from your plan.

Look for the specific service that was denied, the reason code and explanation, the deadline to file your appeal, and the instructions on where to send it. Keep this notice - you will need to reference it in your appeal letter. If you are having trouble understanding the codes and charges, getting help to analyze your medical bills can make the process much easier.

The 5 Levels of Medicare Appeals

The appeals system is structured as a five-step ladder. Each rung is handled by a completely separate reviewer, so a "no" at one level does not prejudice the next. This independent review structure is one of the strongest consumer protections in the entire Medicare program. For a walkthrough of every step, see our appeal guide. Each level gives you a fresh set of eyes on your case.

Level 1: Redetermination. You have 120 days from the date on your MSN to file. A different person at the same Medicare Administrative Contractor reviews your claim. Include a clear appeal letter, your Medicare number and claim details, a letter from your doctor explaining medical necessity, and all supporting documents like medical records and test results. Roughly half of Level 1 appeals result in a full or partial reversal.

Level 2: Reconsideration. If Level 1 is denied, you have 180 days to request reconsideration. A Qualified Independent Contractor - completely independent from Medicare - reviews your case from scratch. You can submit additional evidence at this stage, and you should if you have it.

Level 3: Administrative Law Judge Hearing. You have 60 days to request a hearing after Level 2. The minimum amount in dispute must be $185 for 2026. You can present your case by phone or video conference. This is where having an advocate or representative makes a real difference.

Level 4: Medicare Appeals Council Review. You have 60 days after Level 3 to file. The Appeals Council can review, modify, or reverse the ALJ decision, or send your case back for a new hearing. This is more of a legal review than a new hearing.

Level 5: Federal District Court. The final level. You have 60 days after Level 4, and the minimum amount in dispute is $1,850. You will likely need legal representation at this stage.

Appeal Deadlines at a Glance

Tips to Strengthen Your Appeal

1. Act quickly. Do not wait until the deadline approaches. The sooner you file, the sooner you get a decision and the more time you have to escalate if needed.
2. Get your doctor involved early. A detailed letter of medical necessity from your treating physician is the single most important piece of evidence. The letter should reference your specific diagnosis, explain why the denied service was needed, and cite clinical guidelines that support the treatment.
3. Keep detailed records. Save copies of every document you send and receive. Note the dates of phone calls, the names of people you speak with, and what was discussed.
4. Be specific in your appeal letter. Reference the exact claim number, date of service, and denial reason. Vague language like "I need this service" is less effective than "This service is medically necessary because my diagnosis of [condition] requires [specific treatment] as supported by [clinical guideline]."
5. Include all supporting evidence. Medical records, lab results, prescription history, letters from specialists, and photos if relevant.
6. Request an expedited review if your health is at risk. Medicare Advantage plans must respond to expedited requests within 72 hours.
7. Do not give up after Level 1. Each level brings a fresh, independent review. The odds of success increase as you escalate because each reviewer brings a new perspective.

Medicare Advantage Appeals: Key Differences

Medicare Advantage appeals follow the same five-level structure as Original Medicare, but the timeline is compressed. Your plan must respond to Level 1 appeals within 30 days for standard claims and just 72 hours for pre-service claims. Your plan must continue providing coverage during the appeal in some situations, particularly if you are currently receiving the service and your plan is trying to stop it.

If your plan does not respond by the deadline, your case automatically moves to Level 2.

Read the complete breakdown: How to Appeal a Medicare Denial Step by Step

Part 6: What a Patient Advocate Actually Does (and Why You Might Need One)

If you have ever stared at a medical bill that made no sense, spent 45 minutes on hold with Medicare, or felt like your doctors were not talking to each other, you already understand the problem. The healthcare system was not built for patients. It was built for billing departments. A patient advocate exists to tip the scales back in your favor.

What Does a Patient Advocate Do Day to Day?

A Medicare patient advocate handles the work that falls between the cracks of your medical care - everything your doctor does not have time for and everything your insurance company hopes you will not figure out.

In practice, that means:

Here is what that looks like day to day. They coordinate between your doctors and specialists so they are all working from the same page.

They also review and dispute medical bills (billing errors affect roughly 8 out of 10 hospital bills), filing insurance appeals with the right documentation and deadlines, reviewing your medications for dangerous interactions and helping find lower-cost alternatives, preparing you for appointments so nothing gets missed, and navigating the maze of Original Medicare, Medicare Advantage, Medigap, Part D, and MLTC plans.

When Do You Need a Patient Advocate?

Not everyone needs an advocate all the time. But you should consider getting one if you were recently diagnosed with a chronic condition, you are managing care across three or more doctors, you received a medical bill over $500 that you do not fully understand, Medicare denied a claim or prior authorization, you are transitioning from a hospital stay to home care, you are a caregiver for an aging parent and can't keep up with the paperwork, or you feel like your concerns are not being heard during appointments.

Most people do not look for an advocate until they are already in crisis. A surprise bill shows up, a treatment gets denied, or a loved one is discharged from the hospital with no clear plan. Getting an advocate before the crisis hits gives you a much stronger starting position.

How to Get a Patient Advocate

1. State Health Insurance Assistance Programs (SHIP). Every state has a free SHIP program funded by the federal government. SHIP counselors help with Medicare questions, plan comparisons, and billing disputes. Call 1-877-839-2675 to find your local office.
2. Medicare Advantage plan care coordinators. If you are enrolled in a Medicare Advantage plan, your plan may include a care coordinator or case manager. Call the member services number on your insurance card.
3. Hospital patient advocates. Most hospitals with more than 100 beds have a patient advocate or ombudsman on staff.
4. Virtual patient advocacy services. Companies like Understood Care provide remote advocacy that covers care coordination, bill review, and insurance navigation. Virtual services work nationwide and do not require you to travel anywhere.
5. Your doctor's office. Some primary care practices now employ care navigators or social workers who can help coordinate your care.

How Much Does a Patient Advocate Cost?

Most Medicare patients pay $0 for advocacy services. SHIP programs are federally funded and completely free. Hospital advocates are included in your care. Medicare Advantage care coordinators are covered by your plan.

Private patient advocates typically charge between $75 and $250 per hour, but even when advocacy costs money, it often pays for itself. If an advocate catches a $3,000 billing error or wins an appeal on a denied surgery, the return on that investment is immediate.

Patient Advocate vs Case Manager

These roles overlap, but they are not the same thing.

A case manager typically works for your insurance company or hospital - their job is to manage your care within the system's rules and budget. A patient advocate works for you. Their loyalty is to your health outcomes and your wallet, not to the institution. That distinction matters most during disputes. If your Medicare Advantage plan denies a prior authorization, your plan's case manager represents the plan. Your advocate represents you.

Read the complete breakdown: What Does a Medicare Patient Advocate Actually Do?

Frequently Asked Questions

Can I be a CDPAP caregiver for my parent?

Yes. Adult children are the most common CDPAP caregivers in New York. Your parent needs active Medicaid coverage and approval through their Managed Long-Term Care plan. No medical certification is needed on your end - your parent trains you on what they need help with.

Do CDPAP caregivers pay taxes on their earnings?

Yes - CDPAP wages are treated like any other employment income. Your fiscal intermediary (PPL in New York) handles all withholdings, including federal and state taxes, Social Security, and Medicare. You will receive a W-2 each January for the prior year's earnings.

Can I work as a CDPAP caregiver and keep my Medicaid benefits?

This is an important consideration for caregivers who also receive Medicaid. Since CDPAP wages count as household income, higher hours could theoretically push you above Medicaid's income threshold.

In practice, most caregivers stay well within the limits, but it is worth checking. If your earnings push you above Medicaid's income threshold, you could lose your own coverage. Talk to your local benefits counselor before starting to understand how caregiver income affects your specific situation.

What happens if my CDPAP caregiver calls out sick?

This is one trade-off of the self-direction model. Because you are the employer, there is no agency dispatch to send a fill-in worker. The practical solution is to train a second person as a backup before you need one. Many families designate a second caregiver through the program as a backup. We recommend having at least one alternate caregiver registered with your fiscal intermediary.

Can I switch from traditional home care to CDPAP?

Yes. Contact your MLTC plan or local Department of Social Services to request the change. You will still need to meet the self-direction requirement, but your existing assessment and authorized hours can often carry over without a new evaluation.

Is Medicare Part A really free?

If you or your spouse worked and paid Medicare taxes for 10 or more years, the Part A premium is $0. You still pay the $1,676 deductible if you are admitted to the hospital, but there is no monthly bill for the coverage itself. People with fewer than 10 years of work history pay up to $518 per month.

What is the difference between Original Medicare and Medicare Advantage?

Original Medicare is Part A plus Part B administered directly by the federal government. Medicare Advantage (Part C) is an alternative offered by private insurance companies. Advantage plans must cover everything Original Medicare covers but often add extras like dental, vision, and prescription drugs. The tradeoff is that Advantage plans usually require you to use a network of doctors and get referrals for specialists.

Does Part B cover prescription drugs?

There is a common point of confusion around drug coverage. Part B only pays for medications given directly by a healthcare provider - think chemotherapy infusions or shots administered in a doctor's office. Everything you pick up at a pharmacy. For that, you need a separate Part D plan. If medication costs are a concern, ask your pharmacist about generic alternatives or visit medicare.gov to compare Part D plans.

How long do I have to appeal a Medicare denial?

Timing matters. Original Medicare gives you 120 days from your MSN date to file a Level 1 appeal. Medicare Advantage plans allow 60 days from your Explanation of Benefits. Mark the deadline on your calendar the day you receive the notice - these windows are strict. Always check the specific deadline printed on your denial notice.

What is the success rate for Medicare appeals?

The odds are better than most people expect. Roughly one in two Level 1 appeals ends with the denial being reversed in full or in part. Your chances improve with strong supporting documentation. Appeals with a detailed letter of medical necessity from the treating physician have a significantly higher success rate.

Can someone else file an appeal on my behalf?

Yes, and many people do exactly that. Any trusted person can serve as your appointed representative - a son or daughter, a friend, your physician, a lawyer, or a professional patient advocate. The process requires completing an Appointment of Representative form (CMS-1696).

Does Medicare pay for a patient advocate?

Medicare does not directly pay for a personal advocate, but free help exists. Every state has a federally funded SHIP program that provides Medicare counseling at no charge. Many hospitals also have patient advocates on staff. Private advocates typically charge $100 to $250 per hour, but most people never need to pay out of pocket.

Can a family member be a patient advocate?

Yes, especially with a signed healthcare proxy or power of attorney. However, professional advocates bring specialized knowledge of Medicare rules, billing codes, and appeal procedures that family members usually do not have.

Can I use CDPAP if I live in assisted living or a nursing home?

No - CDPAP services are designed for people living at home, whether that is your own residence or a family member's home. The one exception is transition planning: if you are currently in a facility and preparing to discharge, you can begin the CDPAP application as part of your discharge plan. Once you are home, services can start. If you are transitioning home from a facility, you can apply for CDPAP as part of your discharge plan.

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