Medicaid Benefits in New York

Table of Contents

Medicaid is a state and federally funded program for New York residents who can’t afford medical care.

The program provides a number of services, depending on the beneficiary’s age, income, and family situation. With over 6.4 million people covered— about one-third of the state’s population—New York has one of the largest Medicaid programs in the country.

Read on to learn more about New York Medicaid benefits (like CDPAP), eligibility requirements, and the application process.

Medicaid Benefits Available For New York Residents

Medicaid offers a wide range of health services for eligible New York State residents, including:

Doctor and clinic visits
Regular medical checkups and follow-up care
Medicine, medical supplies, and medical equipment such as wheelchairs, crutches, canes, etc.
Drug prescriptions. Health care providers are required to select the cheapest option of the drugs they prescribe to a Medicaid beneficiary.
Some over-the-counter medications
Smoking cessation agents (medicines used to assist in quitting smoking)
Laboratory tests
X-ray services
Immunizations

Essential dental services
Eye exams. New York Medicaid reimburses eye exams every two years, medically necessary eyeglasses, as well as contact lenses
Custodial care or assistance with activities of daily living in a nursing facility
Care through home health agencies and personal care
Hospital inpatient and outpatient services
Treatment in psychiatric hospitals for patients under the age of 21 or those 65 and older, mental health facilities, and facilities for the mentally retarded or the developmentally disabled individuals
Family planning (birth control) services
Early periodic screening, diagnosis, and treatment for children under the age of 21
Emergency care
Emergency ambulance transportation to a hospital
Non-emergency transportation to medical appointments using public transportation, personal vehicles, taxis, wheelchair vans, and ambulances
Prenatal care. For pregnant women whose income is too high to qualify for full Medicaid coverage, these services may be limited to perinatal care.

Below are some services that are not covered by Medicaid:

Most over-the-counter medications
Missed appointments
Cosmetic surgery
Medical services provided outside of the US.

Will I Have to Pay Copayments?

Copayment is a fixed amount that you are required to pay for a covered health care service after you’ve paid your deductible. States can impose copayments on most Medicaid-covered benefits. The amounts charged vary with income.

The following Medicaid services in New York are subject to a copayment:

Clinic visits
Emergency room visits for non-urgent or non-emergency services
Inpatient hospital stays with at least one overnight stay
Laboratory tests performed by an independent clinical laboratory, a hospital-based laboratory, or a free-standing clinic laboratory
Medical supplies such as syringes, bandages, gloves, ostomy bags, heating pads, hearing aid batteries, nutritional supplements, etc.
Pharmacy prescription drugs and non-prescription drugs.

Some services are exempt from a Medicaid copay, for example:

Emergency services
Family planning services
Pregnancy-related medical services
Preventative services for children, such as immunization, screening, clinical and behavioral interventions
Psychotropic drugs and tuberculosis drugs
Services for individuals with incomes below 100% of the federal poverty level
Services for terminally ill patients
Services for individuals residing in an institution, nursing home, or hospice
Services for patients in a managed care plan, with the exception of pharmacy services
Services for American Indians and Alaska Natives who have previously received a service from the Indian Health Service, tribal health programs, or are under contract health services referral.

Medicaid copayment limit

As a New York Medicaid recipient, you will be asked to pay up to $200 in a copay year that runs from April 1st to March 31st. Once you have reached the maximum, you will receive a letter exempting you from Medicaid copayments until the next period.

Can I be refused services if I can’t pay a copayment?

Because Medicaid covers low-income and often very sick patients, health care services cannot be withheld for failure to pay. However, enrollees may still be held liable for unpaid copayments.

How Do I Know If I Qualify for Medicaid?

To be eligible for New York Medicaid, you must meet the following criteria:

Be a resident of the State of New York
Be a US citizen, national, permanent resident, or legal alien. Undocumented immigrants are eligible for Medicaid only for emergency treatments and prenatal care
Need health care and/or insurance assistance
Have a financial situation that can be defined as low income or very low income.

The following populations are eligible for Medicaid in New York:

Children under the age of 18
Anyone responsible for a child under the age of 18
Pregnant women
People who are certified blind by the Commission for the Blind and Visually Handicapped
Individuals with a disability or who have a family member in the same household with a disability, certified disabled by Social Security or New York State
People aged 65 or older.

Furthermore, your New York Medicaid eligibility will depend on your household size and income. Medicaid considers two financial categories when determining your eligibility: income (Social Security, a pension, or an IRA that is in distribution) and resources (assets such as savings, stocks, bonds, real estate, or an IRA that is not in distribution). The income and resources of legally responsible household members are also counted.

You can also be eligible for Medicaid if you meet certain other financial requirements, for example:

You have high medical bills, even if your income and resources are above the allowed Medicaid income levels.
You receive Supplemental Security Income (SSI).

Expanded income levels are available for children and pregnant women as follows:

Children from birth until the age of one and pregnant women – 223% of the federal poverty level
Children 1-18 years old – 154% of the federal poverty level.

Income and resource levels are subject to yearly adjustments.

MAGI and non-MAGI Medicaid

There are two different types of Medicaid: Modified Adjusted Gross Income (MAGI) and Non-MAGI.

MAGI Medicaid takes into account your gross income to determine whether you are eligible for benefits. Recipients of MAGI Medicaid receive so-called “benchmark benefits” that cover the same services as Medicaid except for long-term care in an institution such as a nursing home. There are no asset limits for MAGI Medicaid.

The following categories are eligible for Medicaid under the MAGI program:

Pregnant women
Infants and children under the age of 19
Children in foster care
Childless adults aged 19-64 who are not pregnant, not on Medicare, and could be certified disabled
Parents or caretaker relatives
People who are on a family planning benefit program.

On the other hand, non-MAGI Medicaid covers essential health benefits (EHBs). Non-MAGI Medicaid eligibility groups include:

Individuals who are age 65 or older and who are not a parent or caretaker relative
Individuals who are blind or disabled and who do not meet the criteria of any of the MAGI eligibility groups.

Some applicants have the possibility to choose between MAGI or Non-MAGI Medicaid:

Anyone under the age of 65 who is certified as being disabled and is not on Medicare
Parent/caretaker relatives who are disabled or 65 or older, regardless of whether they receive Medicare
Disabled children, unless they are in a waiver program.

Child/Teen Health Program (C/THP)

For children under the age of 21, Medicaid offers the Child/Teen Health Program (C/THP) with an emphasis on preventive care and treatment, such as screening with a blood lead test at the ages of one and two. The program is available from all fee-for-service healthcare providers. In addition, all managed care plans must offer C/THP to Medicaid recipients under the age of 21 who are enrolled in their plan.

Community and Chronic Medicaid

New York State offers Community and Chronic (Nursing Home) Medicaid programs for seniors in need of long-term care. While Community Medicaid covers care at home and some assisted living residences, Chronic Medicaid covers nursing home care. Both programs have income and resource limits for eligibility, although the rules are somewhat stricter for Chronic Medicaid.

How Do I Apply for Medicaid?

Where you apply for Medicaid will depend on whether you are single, a childless couple, pregnant, parent or caretaker relative with dependent children, elderly, and/or disabled.

There are several different ways to apply for Medicaid in New York:

The New York State of Health Marketplace

The NY State of Health Marketplace offers public and private health insurance options for individuals and families. Most people whose incomes are just above the level to qualify for Medicaid can pay low premiums and out-of-pocket costs for private health insurance through the Marketplace.

The following individuals must apply for Medicaid through the NY State of Health Marketplace:

Adults aged 19-64 who are not eligible for Medicare
Pregnant women and infants
Children aged 1-18
Parents and caretaker relatives.

You should apply through the New York State of Health Marketplace for MAGI Medicaid.

Pregnant women can also apply through one of the Family Planning Benefit Program enrollment sites for immediate coverage or through the NY State of Health.

For more information, call (855) 355-5777 (office hours: Monday – Friday 8 am – 8 pm, Saturday 9 am – 1 pm).

To find your nearest enrollment assistance, consult the Navigators and Certified Application Counselors directory. Navigators and Certified Application Counselors (CAS) will assist you in your application process through Marketplace free of charge.

Local Department of Social Services (LDSS)

To apply for Medicaid, you can visit your Local Department of Social Services (LDSS) in person. You are eligible to apply through an LDSS if you belong to one of the following categories:

People aged 65 and older who are not parents or caretaker relatives, when age is a condition of eligibility
Former foster care youth
Individuals whose eligibility is based on being blind or disabled or who request coverage for community-based long term care (CBLTC) services, including anyone with an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS)
Medicare Savings Program (MSP) beneficiaries
Medicaid Buy-In for Working People with Disabilities (MBI-WPD) enrollees
Residents of adult homes and nursing homes
Residential treatment center/community residences operated by the Office of Mental Health (OMH).

You can enroll in non-MAGI Medicaid by applying at an LDSS.

New York State Department of Health publishes a directory of the Local Local Department of Social Services by county.

Human Resources Administration (HRA)

The following individuals must apply for Medicaid through New York City’s Human Resources Administration (HRA):

People over the age of 65 who are not a parent or caretaker relative of minor children
Individuals who have Medicare, and
People seeking to qualify for Medicaid based on a disability.

Call the HRA at (347) 396-4705 for free enrollment assistance, where trained enrollers will help you apply for Medicaid. Alternatively, you can visit your local HRA’s Medical Assistance Program Office.

Managed Care Organization (MCO)

You can apply for Medicaid directly through a Managed Care Organization (MCO).

New York State Department of Health publishes a directory of Managed Care Organizations by plan and by county.

Download the Medicaid application form

You can download the Medicaid application form from the NYS Department of Health website. The PDF includes the list of all the required documentation and detailed instructions on how to complete the form.

Get help to apply for Medicaid

If you are 65 and over and/or living with a disability or blindness, you can get free help applying for Medicaid through NYC’s Facilitated Enrollment for the Aged, Blind and Disabled Program.

Phone: (800) 544 8269

Email: csubia@healthsolutions.org

You can also obtain in-person help if you are applying through the NY State of Health Marketplace. Call 311 to find an in-person assistor, such as a Navigator, a Certified Application Counselor, or a Certified Marketplace Facilitated Enroller.

If you are not sure if you qualify, you can still apply for Medicaid NY. You can expect to receive a response within 45-90 days.

For more information, visit the official Medicaid website or call one of the following services:

Medicaid helpline at (800) 541-2831
New York State Health Department’s Growing Up Healthy Hotline at (800) 522-5006
Your local county Department of Social Services
The New York City Information Hotline at 311 or (718) 557-1399.