CDPAP Resources

A Guide to Medicaid in New York

A Guide to Medicaid in New York

Medicaid plays a crucial role in providing healthcare access to vulnerable populations, including low-income individuals and families, children, pregnant women, people with disabilities, and the elderly. It helps ensure that these individuals have access to necessary medical services and can receive care even if they cannot afford private health insurance. Medicaid income and resource levels generally change on January 1 of each year.

What is Medicaid?

Medicaid is a joint federal and state government program in the United States that provides healthcare coverage to low-income individuals and families. It was established in 1965 alongside Medicare as part of the Social Security Amendments, and it is administered by both the federal government and individual state governments. Medicaid is the largest source of health insurance coverage for low-income Americans.

Each state has its own Medicaid program, allowing flexibility in designing and managing the program. Since Medicaid is an entitlement program, individuals and families must meet the eligibility requirements before enrolling.

Who Is Eligible for Medicaid in New York?

Eligibility for Medicaid is primarily based on income and family size. Each state sets its own income limits and may have different criteria for eligibility, so the specific rules can vary from one state to another. In some cases, eligibility may also be based on factors like disability, age, and pregnancy. Children and families may be eligible for Child Health Plus or Family Health Plus if they are not eligible for Medicaid.

In New York, the general guidelines for Medicaid eligibility are: You must be a resident of the state of New York, a U.S. national, permanent resident, or legal alien, in need of health care/insurance assistance, whose financial situation can be characterized as low income or very low income. You must also be one of the following:

  • Be pregnant, or
  • Be responsible for a child 18 years of age or younger, or
  • Blind, or
  • Have a disability or a family member in your household with a disability, or
  • Be 65 years of age or older.

Additionally, you must have an annual household income (before taxes) that is below the following amounts:

*For households with more than eight people, add $6,836 per additional person. Always check with the appropriate managing agency to ensure the most accurate guidelines.

How to Apply for NY Medicaid

If you meet the criteria above, you are eligible and can move forward with your Medicaid application. It’s common for Medicaid applications to get rejected due to incomplete data. Before submitting your application or visiting an office to get assistance with your application, make sure you have all of the necessary documentation:

  • Birth certificate
  • Proof of citizenship
  • Proof of income (Tax return, pay stubs, Social Security, or any other form of income source)
  • Copies of bank statements for proof of assets/finances.
  • Proof of residences
  • Proof of other insurance (if applicable)

You can apply for NY Medicaid in the following ways:

  • Through NY State of Health
    • Through a Managed Care Organization (MCO)
    • Call the Medicaid Helpline at (800) 541-2831

What Services Does Medicaid Offer?

Medicaid provides comprehensive healthcare coverage, including doctor visits, hospital care, prescription drugs, preventive services, and more. States have some flexibility in determining the specific services covered under their Medicaid programs. For some pregnant women, services may be limited to perinatal care if their incomes are too high to qualify for full Medicaid coverage.

Medicaid offers a full range of health services for eligible persons including:

  • All regular medical checkups and needed follow-up care.
  • Immunizations.
  • Doctor and clinic visits.
  • Medicine.
  • Medical supplies.
  • Medical equipment and appliances (wheelchairs, etc.).
  • Lab tests and x-rays.
  • Eye care and eyeglasses.
  • Emergency care.
  • Dental care.
  • Nursing home care.
  • Emergency ambulance transportation to a hospital.
  • Hospital stays.

For children birth to 21 years old, Medicaid offers the Child/Teen Health Program (C/THP), which provides the services listed above for all Medicaid recipients. C/THP places an emphasis on preventive care and treatment. For example, Medicaid requires that all children be screened with a blood lead test at one and two years of age. C/THP is available from fee-for-service healthcare providers. Also, all managed care plans must offer C/THP to Medicaid recipients under 21 years of age who are enrolled in their plan. Child Health Plus and Family Health Plus provide services to eligible children and adults, respectively, through managed care plans.