Step-by-step guide to enrolling in the NYSARC Pooled SNT for Medicaid spend-down

This article is intended as a condensed road-map for using the NYSARC Pooled SNT to eliminate the Medicaid spend-down.  This article contemplates that the individual is applying for Medicaid in order to obtain home care services.  The sequence of events will be different if that is not the case.

I am leaving out some of the details here, so if you are planning on trying this, I advise you to also review our longer memo on this topic (updated May 2012).  You don't need to have a lawyer to enroll in the NYSARC SNT, but you should have a social worker or someone else familiar with Medicaid to help you.

Step One - Apply for Medicaid Home Care with a Spend-Down

The first step is to apply for Medicaid home care with a spend-down.  In New York, certain categories of Medicaid applicants can get Medicaid health coverage even though their income is over the income limit.  Those who receive Medicaid home care services can "meet" their spend-down by getting billed for their home care.  They will get billed for the amount by which their income exceeds the applicable income limit (e.g., a single person with $1200/mo. countable income would get billed $433/mo [$1200 - $767 = $433]).  It is those clients who are unable to afford to pay this bill who are most appropriate for a Pooled SNT.  Read this memo for more information on eligibility for Medicaid home care.

Step Two - Enroll in the Supplemental Needs Trust

The second step, which can actually start at the same time as the Medicaid application, is to enroll in the NYSARC Community Trust II.  All of NYSARC's documents for this trust, including a Q & A and Procedures, are now posted online (NOTE NYSARC Information and Procedures updated June 2012). There are many other Pooled SNTs in New York, but this one has the most favorable fee structure for monthly contributions of excess income.  Here's what you have to send to NYSARC to enroll in the trust:

• NYSARC Beneficiary Profile & Joinder Agreement, filled out and signed before a notary public (NOTE -- form revised June 13, 2012) -- CLICK ON COMMUNITY TRUST II Joinder Agreement)
• NYSARC Submission Checklist 
• Copy of beneficiary's Social Security card (click here if beneficiary lost their Social Security card)
• Copy of beneficiary's Social Security Award Letter, showing the type of benefit received (e.g., Retirement, Disability, Survivor's) and the claim number (Social Security number).  If you request an Award Letter from the SSA website, you can specify which information you want it to include (e.g., Medicare eligibility dates, date of birth).  It is recommended to include all available information on the Award Letter. (click here to request a new Award Letter)
• Guaranteed funds (cashier's check, certified check, or money order) payable to NYSARC for the initial deposit (minimum initial deposit is $300)

Before NYSARC will pay out any disbursements, you must have paid a $200 nonrefundable fee, plus two times whatever the monthly contribution will be (in the above example this would be $200 + (2 x $433) = $1066).  One month of this is a security deposit which must remain on account at all times.  The second month of this deposit can be used to pay expenses.  If you sent just $300 initially to open the account, $200 of it will be applied to the fee, and $100 will be applied towards the security deposit.  For information about filling out the joinder agreement and how the fees work, see our longer memo.

For help determining the appropriate amount to contribute each month to eliminate your spend-down and obtain the Medicare Savings Program, you can use this Excel worksheet.

Eventually, Medicaid will reduce your spend-down to zero retroactively to the month you began contributing to NYSARC.  For this to work, you must continue sending you spend-down to NYSARC every month.  However, once you are approved for Medicaid homecare with a spend-down, you will be expected to pay your spend-down to the homecare vendor every month, which you will be unable to do because you're sending it to NYSARC.  You can explain to the homecare vendor that your spend-down will eventually be retroactively reduced to zero, and therefore the vendor will be able to back-bill Medicaid for the spend-down.

NYSARC will take about 45 days to process your application, and if you are approved, they will send you a binder with information about how to use the trust.  This binder also includes documents you will have to send to Medicaid to get your spend-down rebudgeted.

Step Three - Notify Medicaid About the Supplemental Needs Trust

The last step is to notify Medicaid that you have a NYSARC SNT account.  For all documents below, send copies and keep the originals for your files.  There are two things you have to show to the DSS: that you are enrolled in an SNT (and making contributions), and that you are disabled:

• Proof of SNT
  • NYSARC Master Trust Agreement 
  • NYSARC Joinder Agreement, signed by both you and the trustee at NYSARC (this was in the binder from NYSARC)
  • Verification of Deposits made to NYSARC (call NYSARC at 800-735-8924 to request this)
  • NYSARC Acceptance Letter (this was in the binder from NYSARC)

• Proof of Disability

  • If you have been approved for either SSDI or SSI benefits on the basis of a disability, then all you have to send to prove disability is a copy of your SSA Award Letter stating that you are disabled.  Otherwise, you need to send the documents below and ask the DSS for a disability determination.

  • DSS-486T - Medical Report for Determination of Disability (Rev. 6/2012))
    This form needs to be filled out by your doctor(s).  In January 2013, HRA published a Medicaid Alert stating that applicable medical records must be included with 486T form.  NOTE:  The 486T form revised in June 2012 shortens this form from a 25-page form to a 2-page form, which will be less intimidating to doctors.   The old form consisted of numerous attachments that elicited information about the different body systems, such as a musculoskeletal or cardiac impairments.  Those  attachments, while burdensome, were helpful to show the criteria for "meeting the listings"-- Step Three in the sequential evaluation process described  in this article.   While no longer required, you might find some of these attachments helpful as a guide for the physician to provide information about particular conditions.  Click here for the old 486T.

  • DSS-1151 - Disability Questionnaire (Rev. 6/2012 to replace Disability Interview Form)
    This form can be filled out and signed by a social worker or family member.

  • LDSS-1151.1 (6/2012) Disability Questionnaire Continuation Sheet - provide names, addresses of all medical providers and hospitals where care received in order for State to obtain medical records.

  • MAP-751D - Authorization for Disclosure of Individual Health Information
    You should submit this form if you want someone else (e.g., social worker or attorney) to be able to talk with the DSS about your case.

  • OCA Official Form 960 - NY State HIPAA
    You should also submit three original copies of this form, signed and dated by the applicant.  See this Medicaid Alert for more information. 

• Cover Letter

  • Enclose a cover letter with this great packet of information, to explain what you are asking the DSS to do (rebudget your Medicaid case with no spend-down) and why (because you have an SNT and are disabled).  You can use this sample cover letter as a starting point.  You should customize it to apply to your specific impairment(s) and the information in the 486 and 1151 forms. 

  • Use the NYS Medicaid Disability Manual as a guide, which explains the "sequential evaluation process" for determining disability, has the Listing of impairments, and other information.

  • You should also ask to be enrolled in the Medicare Savings Program (MSP), to have your Medicare Part B premium paid by the State.  Just as the SNT has brought your income under the limit for Medicaid, it has also brought it under the limit for the MSP.  Click here for more information about this program.

• Government Directives

  • It may help to enclose also copies of the Federal, State, and local directives instructing DSS workers how to process SNT cases.

Once you have submitted the SNT and disability documentation to your DSS, they will typically take many months to process this information.  You should eventually get a notice stating that your Medicaid case has been rebudgeted with no spend-down.  Make sure that the effective date of this notice is correct - it should be the month that you first began contributing your excess income to NYSARC.  If it is not correct, you may have to request a Fair Hearing to appeal the notice (click here to request a hearing).

As you can see, this is one of the most complicated things you can do involving Medicaid.  Many people find that it is worth hiring a private elder attorney to help with this process.  Some free legal services may be available to help, also.  For more in-depth information on SNTs, including how an SNT affects eligibility for other public benefits, see our Training Outline for Advocates.

This article was authored by the Evelyn Frank Legal Resources Program of Selfhelp Community Services, Inc.