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NYS Medicaid: Coverage, Eligibility, Application, and More

Medicaid is both a federal and state regulated and funded program, so every state’s Medicaid program can be slightly different. New York has one of the largest Medicaid programs in the country. About 24% of the New York State population is covered by NYS Medicaid and CHIP (the Children’s Health Insurance Program). That is a huge portion that includes about one out of every five adults, two out of every five kids, five out of every nine disabled people, and five out of every eight nursing home residents.

This NYS Medicaid Guide Includes:

Medicaid Eligibility NY

Your New York Medicaid eligibility depends on your household size and household income. If you read through the qualifications and still are not sure if you qualify, you can go ahead and apply for Medicaid NY. You’ll hear back within 45 days, or 90 if you are applying for disability.

Yearly household income must be at or below the following (2018 numbers, subject to change):

Medicaid Eligibility NY | Medicare Plan Finder

New York Medicaid Benefits

New York Medicaid benefits include regular exams, immunizations, doctor and clinic visits, relevant medical supplies and equipment, lab tests and x-rays, vision, dental, nursing home services, hospital stays, emergencies, and prescriptions.

Medicaid Dental Coverage NY

NYS Medicaid covers all essential dental services. “Essential” means that only medically necessary procedures will be covered, such as extractions to prevent disease. Kids (under 21) can receive a bit more dental care thanks to the EPSDT (Early Periodic Screening, Diagnosis, and Treatment) program. That includes regular oral exams as well as preventative, restorative, and emergency dental care. Kids can also get emergency orthodontic care. Implants, bridgework, dentures, and cosmetic work are NOT included.

Eyeglasses and Healthy Vision

New York Medicaid can reimburse for eye exams every two years, eyeglasses when medically necessary, and contact lenses (with prior authorization). Certain types of glasses and contacts cannot be prescribed primarily for aesthetics. Any surgical procedures or orthoptic training must receive prior approval.

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NYS Medicaid OTC Formulary and Prescription Drug Coverage

The NYS Medicaid formulary is very comprehensive - the PDF is 659 pages long! NYS Medicaid providers (doctors, hospitals, pharmacists) are expected to select the cheapest option of any drug they prescribe to a New York Medicaid beneficiary. In most cases, this means that the generic form of the drug will be selected. If you notice that your doctor prescribes a brand-name drug, ask and make sure that it is the most affordable option. NYS Medicaid may cover brand-name drugs as well, but generic options are almost always cheaper. Generic drugs usually provide the same benefits as their brand-name counterparts.

In some cases, New York Medicaid may provide reimbursements for over-the-counter products as well. To get that reimbursement, your doctor will need to provide a fiscal order, which is sort of like a prescription for over-the-counter drugs and products.

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Medicaid Transportation NYC & NY

The New York State Medicaid program provides both emergency and non-emergency medical transportation to beneficiaries. The transportation program is managed by two different companies: Medical Answering Services and LogistiCare Solutions. The program includes coverage for public transportation, personal vehicles, taxis, wheelchair vans, ambulances, and even commercial airlines when necessary.

Best Medicaid Health Plan NY

Most people with NYS Medicaid will have the chance to select a Managed Care plan. The biggest difference between each plan available in your county will be the network. Not every doctor will accept every plan. If you already have a doctor that you like, be sure to find out which NYS Medicaid Managed Care plans your doctor accepts. The basic benefits will be the same for most of these plans, but the “best” plan may not be the same for you as it is for your neighbor. For example, some plans include family planning services, but others may not.

When you select a Managed Care Plan, you’ll have to select one primary physician who will be the main doctor that you will go to first for most of your health care needs. That doctor can give you referrals for specialists.

You should receive a package about the plans you can choose from when you are accepted into the New York Medicaid program.

Emergency Medicaid NY

Emergency Medicaid is for undocumented and temporary immigrants in New York state. Non-citizens are not able to enroll in Medicaid, but Emergency Medicaid allows low-income immigrants to have access to life-saving emergency care. All NY hospitals are required to treat those with Emergency Medicaid. This is for emergency use ONLY - you will not be covered for doctor visits, prescriptions, etc.

To qualify, you must meet the income limits of regular New York Medicaid. Applying will NOT affect your immigrant status and you will not be reported to Immigration. Coverage lasts for one year, so we recommend signing up NOW so that you are covered if you have a medical emergency in the next year - but don’t forget to sign up again next year! You can also sign up at a hospital during or immediately after an emergency.

For help enrolling, call 347-396-4705 or visit nystateofhealth.gov.

Child Health Plus

The Child Health Plus program is for kids who are not eligible for Medicaid but do not have financial access to quality health care. To qualify, a child must be under the age of 19 and not have any other form of health insurance. You will need proof of age, citizenship, NY residency, and household income. Most families will not pay a premium. Child Health Plus covers:

  • Doctor well-visits and immunizations
  • Illness and injury treatment
  • Inpatient hospital services, including surgeries
  • Short-term therapy services
  • Substance abuse and mental health
  • Prescription and some non-prescription drugs
  • Emergency care and transportation
  • Emergency, preventative, and routine dental care, plus limited orthodontic services when medically necessary
  • Preventative and routine vision care
  • Speech and hearing treatment
  • Hospice
  • Some medical equipment

The chart below will explain how your family size and monthly income relates to your Child Health Plus costs.

Child Health Plus Eligibility | Medicare Plan Finder
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Use the NY Medicaid Doctors List

The best way to find a doctor in your area who accepts New York Medicaid plans is to use a provider search tool like ZocDoc. You can search by location, name, condition, procedure, or the type of doctor you are looking for. You can also use the official NYS Provider and Health Plan lookup tool to search by health plan, provider, or facility.

NYS Medicaid Related Resources

You may not have heard of these resources available to New Yorkers. Do any of these programs apply to you?

Request a Fair Hearing - If you are denied benefits, you have the right to request a fair hearing to explain to a judge why you believe you deserve benefits and your local agency is wrong. The judge may turn you down or may overturn the agency’s decision.

Kinship Navigator - NYS Kinship Navigator is a referral and advocacy program for family caregivers in New York State. This mainly refers to grandparents, aunts, and uncles who care for a family member’s children. Kinship Navigator provides legal and medical information and financial assistance when applicable. Visit the website and click on your county for more information.

Eat Smart New York (ESNY) - ESNY is a free program for those who receive New York SNAP benefits (food stamps). The goal is to encourage New Yorkers to eat more fruits and vegetables, drink less sugary beverages, exercise more, and learn to balance caloric intake.

Temporary Assistance (TA)  - The TA program can help you for a short period of time if you are unable to find work or your job doesn’t pay enough. There are two versions - Family Assistance (FA), and Safety Net Assistance (SNA). Both provide cash assistance to eligible New Yorkers for a maximum of two years. If you still need help after those two years, eligible beneficiaries may be able to provide non-cash assistance that is handed directly to your landlord or utility companies. To apply, complete this form and deliver it to your local Department of Social Services.

Employment and Training Services - The Office of Temporary and Disability Assistance provides employment and training opportunities to those with TA and/or SNAP. Some benefits include child care, transportation, basic education, job skills training, job search and referral assistance, subsidized employment, help paying for work-related expenses (like uniforms and equipment), and workplace accommodations if necessary.

New York Child Support - The Child Support program can help a child find his or her parents, help establish paternity, and assist in the collection and distribution of child support payments. To apply, complete this form and turn it in at your local Child Support office.

HEAP (Home Energy Assistance Program) Heating - Whether you heat your home with gas or electricity, HEAP can help you pay your bills to make sure you can keep your home warm throughout the winter months. Eligibility is based on income, household size, what you use for heating, and whether or not you have very young, old, or disabled people living in your household. Depending on your income and household size, you can get anywhere from $21 to about $350 to help you pay your monthly bills. HEAP may also cover your costs to repair or replace any damaged heating equipment, depending on your eligibility.

HEAP Cooling - Starting in May, eligible HEAP beneficiaries can receive finances to help fund the purchase and installation of an air conditioner or fan.

Click here for more information about HEAP Heating and Cooling in your county.

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How to Apply for Medicaid NY

Even if you’re not sure whether or not you meet the Medicaid eligibility NY requirements, you can go ahead and apply to find out. There are a handful of ways that you can apply for Medicaid NY. You can call NY State of Health for assistance at 855-355-5777, you can call the Medicaid Helpline at 800-541-2831, or you can contact a Managed Care Organization directly. You can also download the application here.

If you qualify for both Medicaid NY and Medicare, we can help you select a Medicare Advantage plan that is designed specifically for those who benefit from both Medicare and Medicaid.

For help sorting through all of your coverage options, complete this form or call us at 833-438-3676.

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