long-term care, and other health-care costs are paid by Medicaid
to service-providers on behalf of recipients of Temporary Assistance
to Needy Families (TANF) and Safety Net (SNA), financially “needy”
families with dependent children, and financially “needy”
and blind individuals, including those receiving Supplemental
Security Income (SSI). Some individuals and families with high
medical expenses whose incomes exceed the various eligibility
levels for Medicaid may be eligible under Medicaid’s Send
There are income tests for all types of Medicaid coverage.
There are net income limits for regular, full Medicaid
coverage and for “overage” which also depends
upon the amount of medical expenses. For pregnant women
and children, the income limits are more liberal than
for regular Medicaid.
To be eligible for regular, full Medicaid benefits in
2006, net monthly income must fall below the following
|Number in Family
||Monthly Net Income
|For each additional person,
Income includes all
earnings from employment; profits from business; interest
from savings; stock dividends; Social Security benefits;
actual contributions from legally responsible relatives;
and any benefits from retirement, disability, union,
veterans’ or other pensions or awards.
Net Income is income
as defined above minus the cost of health-insurance
premiums and Supplemental Security Income (SSI) disregards,
which also apply to aged, blind, and disabled persons
not on SSI (See SSI, Eligibility Conditions:
Income). There is also a “spend down”
provision for net income.
Spend Down: Certain applicants with
incomes over the various eligibility levels who have
high medical expenses may be eligible for Medicaid if
deduction of those expenses would ring their incomes
down to the required level.There are different Spend
Down levels, depending on whether applicants fall into
the federal assistance categories (e.g., SSI), with
the limits being lower for the non-federal categories
(e.g., SNA). (Spend down is also used in relation to
spending of assets, see below).
Persons Eligible for Social Security Since 1972:
Certain recipients of Social Security with incomes somewhat
higher than the figures above may also be eligible.
In order to be eligible for this income disregard, these
individuals must have been eligible for or receiving
public-assistance grants and been eligible for Social
Security in August of 1972.
Pregnant Women and Children: When determining
eligibility for a pregnant woman, appropriate income
disregards are subtracted before determining whether
the remaining income is below the medically needy income
level, the Public Assistance (PA) Standard of Need,
or 100% of the Federal Poverty Level (FPL), whichever
is higher. When the Applicant/Recipient (A/R's) household
income is equal to or less than the appropriate level,
the pregnant woman and any children under age 19 are
fully eligible for Medicaid. If the pregnant woman’s
income exceeds 100% of the FPL for her size family,
her income should be compared to 200% of the FPL. When
the A/R's family income is equal to or less than 200%
of the FPL, the pregnant woman is eligible for Medicaid
coverage of perinatal services.
When determining eligibility for an infant under age
1, the household income of the infant is compared to
the medically needy income level or PA Standard of Need,
whichever is higher. If ineligible under that level,
household income is then compared to 200% of the poverty
level. The infant under 1 is fully eligible for Medicaid
if household income is equal to or less than 200% of
the poverty level.
When determining Medicaid eligibility for a child between
the ages of 1 and 6, the household income of the child
is compared first to the medically needy income level.
If the income exceeds the appropriate level, it should
be compared to 133% of the poverty level. For a child
under the age of 6, with household income above 133%
of the FPL, income must spend down to the medically
needy income/resource levels.
|When determining Medicaid eligibility for a child between
the ages of 6 and 19 years old, the household income of
the child is compared to 100% of the FPL. A child in this
age range with income above 100% of the FPL, income must
spend down to the medically needy income/resource levels
or PA Standard of Need, whichever is higher.
The table below gives the higher or “expanded”
income levels for children and pregnant women.
Expanded Income Levels for Children
and Pregnant Women, 2006
Infants to age one and pregnant women - 200% of the FPL
• Children age 1 to
19 years - 133% of the FPL
|Number in Family
||Monthly Income Effective
January 1, 2006
|| $ 817
|For each additional person, add:
There is an assets test for all Medicaid coverage except
for pregnant women and children under the age of 6. In
order to receive Medicaid in 2006, an individual can have
non-exempt resources of no more than $4,150. Counted as
assets are savings, stocks, bonds, and the cash value
of life insurance policies over $1,150. Not counted are
the home in which the applicant resides, one licensed
car in use by the applicant/recipient, furniture, clothing,
|Number in Family
|For each additional
NOTE: If applicants transfer
real or personal property for less than fair market value
within 36 months of their application for Medicaid, and
in some instances, to and from trusts within 60 months,
such transfers or assignments may lead to denial of assistance,
or reduction of such coverage as care in a skilled-nursing,
health-related, intermediate-care, residential-treatment
facility, Longer-term Home Health Care Program with Waivered
Services, Alternate Level of Care days in a hospital and
In order to be eligible for Medicaid, applicants must
“spend down” their resources to the allowable
level for the size of that family.
There is no assets test for pregnant women with incomes
under 200% of the Federal Poverty Level.
Not a condition, but persons 65 and older are among those
who are eligible for Medicaid if they are financially
needy or receiving SSI.
Not a condition, but persons who are disabled are among
those who are eligible for Medicaid if they are financially
needy or receiving SSI. The applicant must submit documentation
of disability. A disability must meet rigid criteria before
an individual can be declared permanently disabled.
Presence of Spouse:
Not a condition.
Needy adults who are neither disabled nor elderly are
only eligible if they have dependent children or qualify
for catastrophic coverage.
Not a condition.
Exhaustion of Benefits From Other Programs:
Applicants covered by Medicare or private health insurance
must exhaust benefits from these programs before Medicaid
can become available. The same is true of Veterans’
Benefits. Medicaid will, however, pay enrollment fees
for the medical-insurance premium in Medicare (which covers
part of outpatient costs) for recipients of cash grants
under TANF, SSI, or for some former SSI recipients.
Parents should know that when the family’s TANF
benefits end, children may qualify for transitional Medicaid
coverage for 12 months. Or, they may qualify for Medicaid
themselves if the family’s income meets the Medicaid
|Job Search (Employment/ Work Requirements):
Needy adults who are not aged, blind, disabled, who do
not meet the requirements for TANF, and who are not employed
must comply with certain work rules.
Participation in Work Program:
See Job Search.
Not a condition.
Applicants must be residents of New York State for more
than 90 days. Applicants must be U.S. citizens, who have
been lawfully admitted to the U.S. for permanent residence
under the Immigration and Nationality Act (INA); who have
been granted asylum under the INA; who have been admitted
to the U.S. as a refugee under the INA (including Amerasian
immigrants admitted under the provisions of Public Law
100-202); who have been paroled into the U.S. under the
INA for a period of at least 1 year; whose deportation
has been withheld under the INA; who are Cuban and Haitian
entrants [as defined in the Refugee Education Assistance
Act of 1980]; who have been granted conditional entry
under the INA; or who have been determined by the local
social services district to be in need of Medicaid as
a result of being battered or subjected to extreme cruelty
in the United States.
Medicaid coverage is available, regardless of alien status,
if a person is pregnant or requires treatment for an emergency
medical condition. A doctor must certify the pregnancy
or emergency, and all other eligibility requirements must
Other Eligibility Conditions:
Medicaid application must be made within 90 days of the
date that a medical bill was incurred (not necessarily
a hospital bill). Alcohol and drug abuse screening is a Medicaid eligibility requirement for all single individuals and childless couples who are age 21 and over, not pregnant or certified blind/disabled and for federally non-participating parents (i.e., fathers of unborn children and stepparents with no other children of their own in the household).
Medicaid issues a permanent plastic ID card, an electronically-coded
Medicaid card (similar to a credit card) that entitles
recipients to the following types of care: inpatient
hospital services; outpatient hospital services; physician
services; medical and surgical dental services; nursing
facility (NF) services for individuals aged 21 or older;
home health care for persons eligible for nursing facility
services; family planning services; rural health clinic
services and any other ambulatory services offered by
a rural health clinic that are otherwise covered under
the State Medicaid plan; laboratory and x-ray services;
pediatric and family nurse practitioner services; federally-qualified
health center services and any other ambulatory services
offered by a federally-qualified health center that
are otherwise covered under the State plan; nurse-midwife
services (to the extent authorized under State law);
and early and periodic screening, diagnosis, and treatment
(EPSDT) services for individuals under age 21.
A pregnant woman may be presumptively eligible for Medicaid
on the date that a qualified provider screens her reported
family income and determines that it falls below 200%
of the poverty level. When the local social services
office completes her eligibility determination and finds
her eligible for Medicaid, a pregnant woman may also
receive inpatient care. Fully eligible pregnant women
with family incomes below 100% of the FPL may receive
all Medicaid covered services.
New York State covers “medically necessary”
(as determined by the doctor) abortions for women whose
incomes are at the Medicaid level or less than 100%
of the Federal Poverty Level.
Covered by Medicaid are:
Hospice Program Services when provided by an organization
certified under Article 40 of the NYS Public Health
Law; Fee-for-service wraparound benefits subject to
State Plan provisions; Long Term Care Services, including
Long Term Home Health Care; Personal Care Services provided
by a certified home health agency; Prescription and
Non-prescription Drugs/Medical Prescription and Non-prescription
Drugs/Medical Supplies/Enteral Formula; and Skilled
Nursing Care not in contract.
Behavioral Health Services: Chemical Dependence
Inpatient Rehabilitation and Treatment Services and
Medically Supervised Inpatient and Outpatient Withdrawal
Services when ordered under Welfare Reform; Methadone
Maintenance; Outpatient Alcoholism Rehabilitation Services
or Chemical Dependence Outpatient Rehabilitation Programs
Provided by entities licensed by the New York State
Office of Alcoholism and Substance Abuse Services (OASAS)
or licensed as Chemical Dependence Outpatient Rehabilitation
Programs; Outpatient Chemical Dependence for Youth Programs
(OCDY); Outpatient Substance Abuse Services, Alcohol
Outpatient Clinics or Medically Supervised Ambulatory
Chemical Dependence Outpatient Programs; Outpatient
Chemical Dependence for Youth Programs; Residential
Treatment for Chemical Dependence.
Mental Health Services:
Day Treatment and Continuing Day Treatment and Day Treatment
for Children; services provided to seriously emotionally
disturbed children under a home and community based
services waiver; Intensive Case Management for the seriously
and persistently mentally ill; Intensive Psychiatric
Rehabilitation Treatment Programs; services provided
by the New York State Office of Mental Health (OMH)
designated clinics for children who are seriously emotionally
disturbed; Rehabilitation Services through OMH Licensed
Community Residences and Family Based Treatment Programs.
Adult Day Health Care; AIDS Adult Day Health Care; Directly
Observed Therapy for Tuberculosis Disease (TB/DOT);
services to children aged
0 - 2 years with a developmental delay or diagnosed
physical or mental condition that is likely to result
in developmental delay; Fertility Services; HIV COBRA
Case Management; Preschool Supportive Health Services;
School Supportive Health Services provided to disabled
children aged 5 through 21 years in accordance with
an approved Individualized Education Program. (See VESID
and Special Education).
Note: Some of the above
services ARE covered by the Medicaid fee-for-service
Medicaid Managed care:
Enrollment in a Medicaid Managed care program through a Health Maintenance Organization (HMO), clinic, hospital, or physician group is available at any local department of social services and is a requirement for most recipients in some counties (e.g., Nassau). In joining a managed care program, one chooses a personal doctor who will be responsible for making sure all health care needs are met, including making referrals as required. When Medicaid is approved, the recipient has 60 days to choose a health plan. Recipients who do not have to choose a plan are those with an HIV infection, people in long-term residential drug and alcohol treatment programs; pregnant women receiving prenatal care from a provider not in any plan; people who live in facilities for the mentally retarded and people with similar needs; some developmentally disabled people or physically disabled children who get acre at home or in their community through waiver programs and those who have the same needs; those with long-term health problem being treated by a specialist who is not in any plan; adults who have serious mental illness and children who have serious emotional problems; people unable to find providers in any plan who can serve in their primary language; people who live where a provider is not accessible; recipients of Supplemental Security Income (SSI) or Medicaid-only Supplemental Security Income (MA-SSI); people temporarily living outside of the county; someone scheduled for major surgery in the next 30 days whose provider is not in a health plan; people with end-stage renal disease; foster care children; the homeless; and Native Americans.
Some Medicaid consumers are not allowed to join a health plan and must stay with regular Medicaid. Excluded are people in nursing homes, hospices, or long-term health care programs and demonstration programs; children or adults in state psychiatric or residential treatment facilities; those living in Family Care Homes licensed by the Office of Mental Health; anyone who will get Medicaid for less than 6 months except pregnant women; anyone on Medicaid only after they spend some of their own money for medical needs (spenddown); people with other health insurance; infants under six months who can get Supplemental Security Income (SSI) or infants living with their mothers in jail or prison; anyone in a Recipient Restriction Program; those eligible for both Medicaid and Medicare; blind or disabled children living apart from parents for 30 days or more; and anyone eligible for TB services only.
Health plans are not all the same. To learn more about each health plan, read the list provided by the local social Services office that shows the different plans available, the hospitals they work with and whether the plan offers transportation, dental care and family planning. Everyone in the family must join the dame plan. Once a plan is selected, it may be changed within the first 90 days. When the 90 day period is up, the recipient must remain in the plan for the next 9 months.
Help in choosing a plan is available through an Enrollment Counselor at the local Social Services office or by calling the new York Medicaid Choice HelpLine at 1-888-562-9092. The line is staffed Monday through Friday 8:30 a.m. until 8 p.m. and Saturdays from 10 a.m. until 6 p.m. The call is free and confidential.
Managed care covers most of the benefits recipients will use, including all preventive and primary acre, 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.
All covered services for regular Medicaid are paid, in full, by Medicaid.
Payment for in-patient hospital services provided to a
recipient who is eligible for MA solely as a result of
being eligible for or in receipt of Family Assistance,
Safety Net, or SSI and who is at least 21 years of age
but under the age of 65 will generally be limited to 32
days in any consecutive 12-month period, unless such services
are provided through a program that receives full capitation
Change in Recipient Status:
Medicaid recipients are usually “recertified” annually, or if they are on public assistance, at the
same time that they are recertified for these other programs.
Medicaid recipients should report changes in income, resources,
or family composition to the Department of Social Services
Continuous Medicaid coverage for children (up to the age
of 19) is provided for 12 months following eligibility
determination regardless of any changes in income or circumstances.
Changes in Benefit Levels:
Medicaid benefits are determined by the New York State
Legislature. There is no automatic change in benefits.
A vote of the State Legislature and signature of the Governor
is needed for a change. Changes at the Federal level are
made by Congress with the signature of the President.
| Where and How
Application procedures vary. Applications for TANF or
SafetyNet Assistance are also applications for Medicaid,
and no separate applications are necessary.
All other applicants should apply at local offices of
the Department of Social Services.
An ill or disabled person may have a friend or relative
apply for him/her, making sure to give the person who
applies a note stating that he/she has been given permission
to do so. Workers from the local Department of Social
Services will go to nursing homes or health-related facilities
for the purpose of taking applications.
Application can be made by mail, but a personal interview
must take place (can be with a relative or other representative).
The law states that Medicaid eligibility is to be determined
within 30 days of application, except in determining disability,
and necessary care is not to be denied pending a determination
In New York City, contact the Human Resources Administration
by calling (718) 557-1399. Residents of the five boroughs
of New York City may call toll free at 1-877-472-8411.
For a listing of the Human Resources Administration Medical
Assistance Program offices in the five boroughs of New
York City visit:
Pregnant women and children can apply at many clinics,
hospitals, and Prenatal Care Assistance Program (PCAP)
offices. They should call their local departments of social
services to find out where to apply.
In a facility operated by the New York State Office of
Mental Health, contact the patient resource office. Local
offices are listed at: http://www.omr.state.ny.us/document/medicaid/hp_rsfo.jsp#li
In a facility certified by the New York State Office of
Mental Retardation and Developmental Disabilities, an
applicant should contact the revenue and reimbursement
office. Local offices are listed at:
89% of which were derived from individual and corporate
income taxes in 2005.
||general revenues, which were
derived principally from individual and corporate
income taxes (45%) and sales taxes (28%) in 2003-2004).
||general revenues, which were
derived principally from property taxes (43%), sales
taxes (15%), and individual and corporate income
taxes (13%) in 2003-2004).
The federal administering agency for Medicaid is the Centers
for Medicare & Medicaid Services (CMS) of the United
States Department of Health and Human Services. The New
York State Department of Health administers the program
in the State through the county and city (New York City)
Departments of Social Services. The federal government
requires that states receiving federal funds provide certain
basic medical services. In addition to these, New York
provides services that the federal government designates
as optional as well as some that are not funded by the
Procedures for Appeal: