What is Medicaid?
Medicaid is a program for New Yorkers who can’t afford to pay for medical care.
How do I know if I qualify for Medicaid?
You may be covered by Medicaid if:
- You have high medical bills.
- You receive Supplemental Security Income (SSI).
- You meet certain income, resource, age, or disability requirements.
How do I apply for Medicaid?
You can apply for Medicaid in any one of the following ways: Write, phone, or go to your local department of social services.
Pregnant women and children can apply at many clinics and hospitals. Call your local department of social services to find out where you can apply.
If you are in a facility operated by the New York State Office of Mental Health, contact the patient resource office.
If you are in a facility certified by the New York State Office of Mental Retardation and Developmental Disabilities, contact the revenue and reimbursement office.
When I go for my application interview, what should I take with me?
- Proof of age, like a birth certificate
- Proof of citizenship or alien status*
- Recent paycheck stubs (if you are working)
- Proof of your income from sources like Social Security, Supplemental Security Income (SSI), Veteran’s Benefits (VA), retirement
- Any bank books and insurance policies that you may have
- Proof of where you live, like a rent receipt or landlord statement
- Insurance benefit card or the policy (if you have any other health insurance)
- Medicare Benefit Card
*NOTE: Medicaid coverage is available, regardless of alien status, if you are pregnant or require treatment for an emergency medical condition. A doctor must certify that you are pregnant or had an emergency, and you must meet all other eligibility requirements.
If I think I am eligible for Medicaid, should I cancel any other health insurance I might already have?
No. If you currently pay for health insurance or Medicare coverage or have the option of getting that coverage, but cannot afford the payment, Medicaid can pay the premiums under certain circumstances.
Even if you are not eligible for Medicaid benefits, the premiums can still be paid, in some instances, if you lose your job or have your work hours reduced. If you need help with a COBRA premium, you must apply quickly, to determine if Medicaid can help pay the premium.
You may be eligible for the Medicare Buy-in Program. This program pays your Medicare premiums and deductibles.
If you have Acquired Immune Deficiency Syndrome (AIDS), Medicaid may be able to help pay your health insurance premiums.
If I can’t leave the house, can I still apply?
Yes. Call your local social services office and ask how this can be done.
How do I know if my income and resources qualify me for Medicaid?
The chart below shows how much income you can receive in a month and the amount of resources you can retain and still qualify for Medicaid. The income and resource levels depend on the number of your family members who live with you.
| 2010 Income & Resource Levels* | |||||
|---|---|---|---|---|---|
| Medicaid Standard for Singles People, Couples without Children & Low Income Families |
Net Income for Families; and Individuals who are Blind, Disabled or Age 65+ |
Resource Level |
|||
| Annual | Monthly | Annual | Monthly | ||
| 1 | $8,479 | $707 | $9,200 | $767 | $13,800 |
| 2 | $10,584 | $883 | $13,400 | $1,117 | $20,100 |
| 3 | $12,593 | $1,050 | $15,410 | $1,285 | $23,115 |
| 4 | $14,622 | $1,219 | $17,420 | $1,452 | $26,130 |
| 5 | $16,719 | $1,394 | $19,430 | $1,620 | $29,145 |
| 6 | $18,253 | $1,522 | $21,440 | $1,787 | $32,160 |
| 7 | $19,869 | $1,656 | $23,450 | $1,955 | $35,175 |
| 8 | $21,943 | $1,829 | $25,460 | $2,122 | $38,190 |
| 9 | $23,131 | $1,928 | $27,470 | $2,289 | $41,205 |
| 10 | $24,321 | $2,027 | $29,480 | $2,457 | $44,220 |
| For each additional person, add: | $99 | $2,010 | $168 | $3,015 | |
*Effective January 1, 2010
Income and Resource Levels are subject to yearly adjustments.
You may also own a home, a car, and personal property and still be eligible. The income and resources of legally responsible relatives in the household will also be counted.
Can I be eligible for Medicaid even if I make more money than the chart shows?
Yes, some people can. Pregnant women and children can have higher income levels and no resource limits.
Pregnant women, children, disabled persons, and others may also be eligible for Medicaid if their income and/or resources are above these levels and they have medical bills. Ask your Medicaid worker if you fit into one of these groups.
If an adult has too much income and/or resources and is not eligible for Medicaid, that person may be eligible for:
Expanded Income levels for Children and Pregnant Women
- Infants to age one and pregnant women – 200% of the federal poverty level.
- Children age 1 through 5 years – 133% of the federal poverty level.
- Children age 6 through 18 years – 100% of the federal poverty level.
| Number in Family | 100% FPL** | 133% FPL** | 200% FPL** |
|---|---|---|---|
| 1 | $903 | $1,201 | $1,805 |
| 2 | $1,215 | $1,615 | $2,429 |
| 3 | $1,526 | $2,030 | $3,052 |
| 4 | $1,838 | $2,444 | $3,675 |
| 5 | $2,150 | $2,859 | $4,299 |
| 6 | $2,461 | $3,273 | $4,922 |
| 7 | $2,773 | $3,688 | $5,545 |
| 8 | $3,085 | $4,102 | $6,169 |
| For each additional person, add: | +$312 | +$415 | +$624 |
* Income Levels are subject to yearly adjustments.
** FPL = Federal Poverty Level
If a child has too much income and is not eligible for Medicaid, the child may be eligible for Child Health Plus.
What are my rights?
The Medicaid application, Access NY Health Care, tells you what your rights are when you apply for Medicaid. See the pages titled “Terms, Rights and Responsibilities.” People who receive Medicaid have privacy rights. Medicaid keeps your health information private and shares it only when we need to.
If you wish to apply for Medicaid, contact the local department of social services.You may also contact an enrollment facilitator. They can help you apply for Medicaid and Family Health Plus.
Generally, local districts must determine if you are eligible and send a letter notifying you if your application has been accepted or denied within 45 days of the date of your application. If you are pregnant or applying on behalf of children, the local district has 30 days from the date of your application to determine if you are eligible for Medicaid. If you are applying and have a disability which must be evaluated, it can take up to 90 days to determine if you are eligible.
If you are not satisfied with a decision made by the local social services district, you may request a conference with the agency. You may also appeal to the New York State Office of Temporary and Disability Assistance and request a Fair Hearing.
How do I request a State fair hearing?
You can ask for a fair hearing by:
1) Telephone: You may call the state wide toll free number: 
800-342-3334
; OR
2) Fax Number: (518) 473-6735; OR
3) On-Line: Complete and send the online request form at: http://www.otda.state.ny.us/oah/forms.asp; OR
4) Write: to the Fair Hearing Section, New York State Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York 12201.
Can I still keep part of my income if I am in a nursing home (Residential Health Care Facility) or in an intermediate care facility for the developmentally disabled?
Yes. Under Medicaid you are allowed to keep a small amount for your personal needs. You can also keep some of your income for your family if they are dependent on you. A spouse who remains in the community may also keep resources and income above the levels shown.
Will there be a lien (legal claim) placed on my estate (my assets) when I die?
If you receive medical services paid for by Medicaid on or after your 55th birthday, or when permanently residing in a medical institution, Medicaid may recover the amount of the cost of these services from the assets in your estate upon your death.
What health services are covered by Medicaid?
In general, the following services are paid for by Medicaid, but some may not be covered for you because of your age, financial circumstances, family situation, transfer of resource requirements, or living arrangements. Some services have small co-payments. These services may be provided using your Medicaid card or through your managed care plan if you are enrolled in managed care. You will not have a co-pay if you are in a managed care plan.
- smoking cessation agents
- treatment and preventive health and dental care (doctors and dentists)
- hospital inpatient and outpatient services
- laboratory and X-ray services
- care in a nursing home
- care through home health agencies and personal care
- treatment in psychiatric hospitals (for persons under 21 or those 65 and older), mental health facilities, and facilities for the mentally retarded or the developmentally disabled
- family planning services
- early periodic screening, diagnosis, and treatment for children under 21 years of age under the Child/Teen Health Program
- medicine, supplies, medical equipment, and appliances (wheelchairs, etc.)
- clinic services
- transportation to medical appointments, including public transportation and car mileage
- emergency ambulance transportation to a hospital
- prenatal care
- some insurance and Medicare premiums
- other health services
If you are eligible for Medicaid, you will receive a Benefit Identification Card which must be used when you need medical services. There may be limitations on certain services.
For you to use your Benefit Identification Card for certain medical supplies, equipment, or services (e.g., wheelchair, orthopedic shoes, transportation), you or the person or facility that will provide the service must receive approval before the service can be provided (prior approval).
What is a Medicaid managed care program?
Enrollment in a Medicaid managed care program through a Health Maintenance Organization (HMO), clinic, hospital, or physician group is available at any local departments of social services. You may be required to join a managed care plan. When you join a managed care program, you will choose a personal doctor who will be responsible for making sure all your health care needs are met. The doctor will send you to someone else if you need more help than the doctor can provide.
What does managed care cover?
Managed care covers most of the benefits recipients will use, including all preventive and primary care, inpatient care, and eye care. People in managed care plans use their Medicaid benefit card to get those services that the plan does not cover.
Do I have to join a managed care plan?
In many counties you can join a plan if there is one available and you want to. However, there are some counties where families will have to join a plan. In these counties there are some individuals who don’t have to join. Please check with your local social services department to see if you have to join a plan.
Of special interest to persons with disabilities:
If you think you are disabled, and if you meet the criteria for disability included in the Social Security Act, you may be eligible for Medicaid.
If you believe you are disabled, you must furnish the local department of social services with medical evidence about your impairment(s).
It may be necessary for you to have further examinations and/or tests for the disability to be determined.
The cost of such examinations, consultations, and tests requested by the disability review team, if not otherwise covered, will be paid by the local social services agency.
NOTE: Persons who are denied for reasons of failure to meet the disability criteria are entitled to appeal the disability decision that led to the denial of their application. See the section of this page entitled “What are my rights?“. Any person dissatisfied with the Fair Hearing decision of the New York State Office of Temporary and Disability Assistance may also appeal to the court system.
Local Department of Social Services
If you send an e-mail to Medicaid@health.state.ny.us please include your phone number so they can respond to you as quickly as possible.
The above information is an excerpt from an article entitled Principles of Entrepreneurship by the New York State Department of Health. The full article can be found here.