Income:
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 levels:

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.

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.

Not Covered by Medicaid are:
Medical Services: 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.

Other Services: 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 plan.

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.

Level:
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 payments.

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 office immediately.

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.