Medicaid is a state and federally-funded program that was developed to provide health coverage for low-income individuals. Because Medicaid funding comes from both the state and federal levels, rules and regulation regarding how the program is administered also comes from both state and federal levels.

The federal government designed the basic structure of this program and it sets certain regulations that participating states must follow. States do not have to offer Medicaid coverage, but each state that does maintains its own website covering Medicaid information that eligible beneficiaries can access to find the resources they need.


In the state of New York, Medicaid eligibility is determined on the basis of household income and household size. Anyone can apply for Medicaid and the state will review the application to determine whether or not the applicant is eligible. Once you’ve submitted an application, been deemed eligible, and officially signed up for the program, you need to know what’s covered by Medicaid and what’s not.


Below we present an easy-to read Medicaid guide that discusses what Medicaid pays for to help you better understand the benefits and the limitations of this program. In this article, we provide a short explanation of the coverage criteria and how to sign up for this program. After that, we provide basic information about each of the Medicaid services that are covered in New York.


Eligibility and Coverage Criteria for Medicaid


Medicaid provides coverage to children, pregnant women, parents, individuals with disabilities, and senior citizens. It is currently the largest health coverage entitiy in the United States. Participation in the program is determined by federal law and extends unconditionally to certain groups of people in the state of New York. Families with a low-income, individuals receiving Supplement Security Income (SSI), pregnant women, and children are examples of groups that are automatically eligible for Medicaid.


To understand the coverage criteria for Medicaid, there are two terms that must first be defined:


·       Federal Poverty Level


The Federal Poverty Level is the amount of money that a family must be making in order to qualify for Medicaid. This amount must be less than a certain amount that’s determined by the Department of Health and Human Services. It is based not just on the income amount, but also on the size of the household that must live on that income.


·       Modified Adjusted Gross Income


The Modified Adjusted Gross Income is the total gross income that an individual makes annually. This income includes not just the money that you make at your job, but also benefits, alimony, or child support payments you receive, interest, foreign income and more. All sources of income must be included in this number.


Getting coverage for Medicaid is determined by assessing your financial eligibility along with certain non-financial specifications. The effective date of coverage is either the date when you make your application for the program or on the first day of the month when you applied. In the latter case, you may be eligible to receive retroactive benefits. Indeed, if you were eligible for Medicaid before you applied to the program, you may be eligible to receive coverage for up to 3 months prior to the date of your application. Coverage ends when the individual is no longer eligible for coverage.


Financial Eligibility


Financial eligibility was re-envisioned by the Affordable Care Act of 2010. According to this new paradigm, eligibility for Medicaid is determined using the Modified Adjusted Gross Income. By using this one variable to assess for eligibility using one single application that’s also used to determine eligibility for a variety of government-sponsored programs, makes the process of applying and enrolling in the Medicaid program much easier.


The Modified Adjusted Gross Income is used as the foundational eligibility determinant for most children, parents, pregnant women, and other adults. Eligibility for Medicaid is determined by looking closely at the applicant’s taxes to consider their taxable income and their relationships as defined by the IRS.

This method of determining eligibility for Medicaid replaced the earlier algorithm that was based on a 1996 model from the Aid to Families with Dependent Children program. The most current system for determining eligibility doesn’t disregard income that the state deems irrelevant and it also doesn’t allow for a resource or asset test.


However, though the Modified Adjusted Gross Income does not offer the same type of leniency that was built into the old system, it does make some individuals exempt from the income-counting rules on the basis of blindness or disability. Individuals over the  age of 65 years are also exempt from the Modified Adjusted Gross Income-counting rules. Those who are disabled, blind, or over 65 years of age must meet criteria set by the Social Security Administration.


Medicaid Eligibility Through Enrollment in Other Government Programs


You may not always need to demonstrate eligibility for Medicaid using the Modified Adjusted Gross Income even if you aren’t blind, disabled, or over 65 years of age. People who are members of other government aid programs such as the Supplemental Security Income program or young adults who were formerly foster recipients are automatically eligible for Medicaid at any income level, for example.


The Medicare Savings Program


The Medicare Savings Program makes it possible for Medicaid to pay Medicare premiums, coinsurance costs, and deductibles for beneficiaries. Eligibility for the Medicare Savings Programs is determined using a Supplement Security Income model. Individuals who are eligible for both Medicaid and the Medicare Savings Program are referred to as “dual eligibles”.


Non-Financial Eligibility


In addition to the financial requirements for eligibility for Medicaid using your Modified Adjusted Gross Income, you will also have to meet the non-financial eligibility requirements. They are listed below:


·   You must be a resident of the state where you hope to receive Medicaid.

·   You must be a citizen of the United States or a qualifying non-citizen (e.g. a lawful permanent resident).


How to Sign Up for Medicaid


Signing up for Medicaid is sometimes a complicated process and you may need assistance from Medicaid experts to get through the process from beginning to end, so it’s best to get started as soon as possible if you think you’re eligible for benefits. You’ll begin the online signup process here. This initial online request is typically accepted as a first step by most offices in most states, but it might also be necessary for you to go into a Medicaid office in person as part of your application process.


Below we discuss the process of signing up for Medicaid from beginning to end and provide a list of the documents that you’ll need to sign up for Medicaid and eligibility factors that you may need to substantiate in order for your application to be processed. For assistance with this process, call the New York Medicaid helpline at 855-693-6765.



1. Decide how you’ll start the application process:


Begin by contacting your state’s Medicaid office. (It can take some time to process your application so make contact with this office as soon as there is a clear need for services.)


·   If possible, start your application or make your initial request for Medicaid online. If you have a PDF viewer on your computer, you can download the application form and send it to the appropriate address by regular mail. You can either fill out the application online and then print it, or print it and then fill it out by hand.

·   If you don’t have access to a computer with an Internet connection, you may also begin the application process by contacting your local Department of Social Services by phone. In New York, you can request information or a Medicaid application by calling 718-557-1399.

·   If you’d prefer to start the application process in person, you can also apply by visiting your local Department of Social Services in person. Ask for a Medicaid application to get started. You can complete the application there and hand it in, or complete it at home and then send it in by regular mail.

·   Find a Facilitated Enroller to assist you with the Medicaid enrollment process.


2. Have the necessary documents ready for your in-person interview.


You’ll need certain documents to complete your Medicaid application. Have these documents ready for each individual in your household who is applying for Medicaid benefits. These documents will be used to substantiate demographic information, citizenship, state residency, age, and income and resources for you and the members of your family. If possible, bring copies of one or more of the documents from each category below.


Below are the types of information you’ll need to be able to prove your identity, age, citizenship, and more to the Medicaid interviewer along with examples of documents that you could use for this part of the process.


·   Social Security Card


·   Proof of citizenship


Federal law states that Medicaid applicants must either prove that they are a U.S. citizen or a legal immigrant with no less than 5 years of residency in the U.S.


Your citizenship can be proven by providing any of the following:

o   Original U.S. birth certificate

o   U.S. passport

o   Certificate of citizenship

o   Certificate of naturalization

o   Green card


·   Proof of age

o   Driver’s license

o   Passport

o   Proof of age card

o   Original U.S. birth certificate


·   Proof of residence


In New York, Medicaid applicants must prove that they are current residents of the state. Below are documents that you can use to prove residency in the state of New York to prove eligibility for Medicaid:


o   Utility bills with your name listed on it

o   Official correspondence from a government agency, sent to your address with your name on it

o   New York driver’s license with your name on it and your New York address listed.


·   Information about other types of insurance you carry:


o   Insurance information for all types of health insurance you currently carry


·   For blind or disabled individuals and those over 65 years of age ONLY:


You must provide proof of income and resources by providing the following documents:


o   Tax returns

o   Pay stubs

o   Social Security payment statements

o   Child support payment statements

o   Proof of sources of income not earned at a regular job


·       Household composition and pregnancy status do not usually require formal verification.


3. Interview in-person with a Medicaid representative.


A Medicaid representative may call you to set up an in-person interview as part of your application process. Interviews are not always required, but if someone contacts you to do an interview, be sure to have your documentation ready.

If you are called in to do an interview, that does not necessarily mean that you won’t be accepted into the Medicaid program, but rather that Medicaid workers need to verify certain aspects of your identity. Gather the documents listed above and have them organized and ready for presentation.


During the Medicaid interview, be honest about your financial situation and immigration status. The interviewer may ask you for different types of documents than those listed above to verify different aspects of your identity. If your income is above the Medicaid income limits, you may still be eligible for other government aid programs.


4.     Wait.


After you’ve completed the steps listed above, you’ll need to wait for 14 to 90 days to receive your Medicaid enrollment card. If you’re approved for Medicaid, you may be eligible for retroactive coverage for medical bills that you incurred up to 3 months before the date of your initial application.


What Medicaid Covers


Medicaid covers a broad array of different health services. Below is a list of the various services that are covered by Medicaid with a brief description of each:


In-Patient and Out-Patient Hospital Services

Hospital care is covered under Medicaid. Inpatient care (care that is provided when the patient stays at the hospital overnight for any period of time) as well as outpatient care (care services given when the patient is able to go home after a hospital visit) are both covered.


Screening, Diagnostic, and Treatment Services

Services such as cancer diagnostic screenings or CAT scans, among other similar services, are covered under Medicaid. Preventative treatment of perceived health issues (such as genetic health issues) are also covered.


Nursing Home Services

For individuals who must live in a nursing home, the costs incurred during their stay may be covered by Medicaid regardless of the length of their stay. This is often a huge relief for elderly individuals or their families who are concerned about being able to obtain affordable care.


Home Healthcare Services

Medicaid recipients are able to receive healthcare in their home, whether it be provided by a loved one under the Consumer Directed Personal Assistance Program (CDPAP) or by a home health professional. CDPAP is a program that provides payment through Medicaid to family members or friends of patients in need of caregiving services. Home healthcare is a mandatory service that’s covered by Medicaid in New York State.


Primary Physician Services

Doctor’s visits and other services provided by the primary physician listed in the Medicaid recipient’s health plan are always covered by Medicaid. These services may include anything from a routine checkup to a visit where a particular treatment is provided for a specific issue or illness.


Rural Health Clinic Services

Rural areas tend to be underserved when it comes to medical services, so Medicaid covers the costs incurred by patients who must visit rural health clinics. The services provided at these clinics vary greatly, but Medicaid patients who must visit these clinics can rest easy that they’ll be covered.


Services of Any Federally-Qualified Health Services Center

All services offered by health centers that are federally funded will be covered by Medicaid. Services provided by these centers may include not only primary health services, but also dental care, mental health care, rehabilitation services, and pharmacy services (among others).


Labs and X-Rays

The costs incurred by lab tests and x-rays are part of the mandatory list of things that are covered by Medicaid in New York State. Medicaid recipients who receive blood tests, x-ray scans, or other kinds of similar tests will be able to receive coverage of the costs of these tests.


Family Planning Services

Family planning services include a range of services, including contraceptive supplies and methods, counseling on contraceptive methods, counseling and referral for sterilization services, screening for reproductive cancers, and screening and counseling for STDs and HIV.


Nurse/Midwife Services

Pregnant women who receive Medicaid may need or want to hire a nurse or midwife to support them through pregnancy and during birth. This is a mandatory service covered by Medicaid in New York State.


Certified Pediatric and Family Nurse Practitioner Services

Family nurse practitioners provide nursing care services for all age groups, including for children, pregnant women, men, and older patients. They are authorized to provide prenatal care, family planning services, minor surgeries, and screening services. Pediatric nurses specifically treat children and babies. Services provided by these two types of nursing practitioners are covered by Medicaid.


Freestanding Birth Center Services

Some women choose to give birth at a birth center instead of at a hospital. A freestanding birth center is a medical institution that is dedicated to helping women give birth, but that is not connected to or affiliated with a hospital. Medicaid is required to cover the costs of services provided by these centers.


Transportation to and from Medical Centers

Coverage of transportation to and from medical centers in New York is mandatory. Most forms of transport, including public transport, private car, and emergency vehicles are covered completely by Medicaid. Emergency transport with airplanes or helicopters may require more proof of the reason why the recipient needed this kind of transport for their medical needs.


Treatment Options for Pregnant Women Who Want to Quit Smoking

Women who smoke while pregnant can confer serious health issues to their unborn child(ren), and thus, many women choose to try to quit smoking during pregnancy. Medicaid provides coverage of the services and treatment options for quitting smoking during pregnancy.


Prescription Medication

Most prescription medications are covered by Medicaid, although there are certain exceptions. Medicaid recipients in New York who take prescription medications will need to check with their local Medicaid center to see if their specific medications can be covered by Medicaid.


Physical Therapy

In the case that a patient needs physical therapy to recover from a surgery, illness, or something else, Medicaid may cover the costs incurred. For some patients in certain situations, the cost of physical therapy may automatically be included in their coverage plan, while for other people authorization may need to be obtained first.


Dental Care

Some types of dental care may be covered by Medicaid. If a Medicaid recipient experiences a debilitating or serious dental issue, they may be able to solicit for coverage of a procedure, treatment, or supplies that are needed to treat the issue. Many dental visits are covered.


Speech, Hearing, and Language Disorder Therapy and Services

Children and adults who need to receive speech, hearing, or language disorder therapy and treatment can submit a request to receive coverage for these services. This is an optional service covered by Medicaid, but patients who are able to prove their need for this service through the use of a physician’s letter (or other means) may be able to receive coverage.


Medical Equipment and Supplies

Medicaid recipients may be able to obtain coverage of the costs incurred from renting or buying medical equipment and supplies in certain cases. Medicaid does not cover the costs of all medical equipment and supplies, but approval may be obtained with a physician’s letter or another form of proof that the equipment/supplies are needed.


Treatment in Psychiatric Hospitals and Other Mental Health Facilities

For individuals under age 21 and over age 65, Medicaid covers treatment and care costs incurred from stays in psychiatric hospitals. For other individuals of all ages, Medicaid covers stays and services at mental health facilities, and facilities for the mentally ill or developmentally disabled.


Eye and Vision Care

Medicaid may cover some vision care services and treatments for certain individuals. Glasses, optometrist appointments, and the cost of other vision care services may be covered if the patient is able to prove a medical need for these services.


Will Medicaid Pay For…. 


Will Medicaid Pay for Past Medical Bills?


Retroactive Medicaid coverage is a special kind of coverage that is designed to help financially needy people obtain financial support for previous medical bills. Retroactive coverage can cover medical expenses incurred up to 3 months before the application date so long as the applicant was eligible for Medicaid during that entire time period. Individuals who apply for Medicaid and are eligible may also sometimes be eligible for retroactive coverage, but not everyone who applies for Medicaid may receive this type of coverage.


Retroactive Medicaid coverage is generally granted to eligible Medicaid applicants who:


1) have met the Medicaid financial eligibility requirements for all 3 of the months prior to applying for Medicaid, and

2) have a functional need, such as the need for assistance when bathing, grooming, dressing, moving around, or eating (among other daily living activities).


Individuals who fulfill the normal Medicaid criteria as well as the above two requirements may be able to obtain retroactive Medicaid coverage for the 3 months of medical bills prior to their official Medicaid application date.


Will Medicaid Pay for Vasectomy?

Yes, Medicaid covers the cost of vasectomy procedures as a part of its family planning services coverage. Individuals who are on Medicaid are eligible to receive coverage of this procedure so long as they visit a provider who accepts Medicaid insurance, even if the provider is outside of the individual’s health plan. The services provided and covered will remain completely confidential. Patients of any age are able to receive coverage of family planning services as long as they can find a medical provider who will work with someone their age.


Will Medicaid Pay for Hep C Treatment?

Yes, since 2016 Medicaid has been providing coverage of treatment for hepatitis C to all diagnosed individuals, regardless of the stage or severity of their condition. Previously, Medicaid only offered coverage to individuals who were in the advanced stages of the illness due to the cost of hepatitis C medications, but recently the New York State Department of Health authorized all Medicaid recipients with hepatitis C to be able to receive treatment and coverage of medications.


Will Medicaid Pay for Weight Loss Surgery?

Medicaid does usually pay for weight loss surgery, with rare exceptions. Gastric bypass, Lap-Band, and gastric sleeve surgeries are among the most popular weight loss surgeries and are almost always completely covered by Medicaid. You will need to receive authorization for these surgeries, but most of the time authorization is granted if you can prove that the surgery is medically necessary. You will need to present this authorization when you pay for the surgery with Medicaid.


Will Medicaid Pay for a Service Dog?

New York Medicaid does not pay for service dogs. These dogs are one of three different kinds of assistance dogs, the other two being guide dogs and hearing dogs, who help the blind and hearing impaired respectively. Service dogs work with people who have disabilities of all kinds, including both psychiatric disabilities as well as physical disabilities. They may help people recognize and appropriately react to medical issues and emergencies such as seizures and severe drops in blood sugar. They may also help autistic individuals or people who have trouble balancing.


Although Medicaid does not cover the expenses related to having a service dog, there are many other organizations and institutions that provide financial assistance for disabled individuals who need or want to have a service dog. For example, the US Department of Veterans Affairs covers the costs associated with equipment and veterinary care for service dogs who are helping veterans.


Will Medicaid Pay for a Lift Chair?

Medicaid in New York will pay for a lift chair in most cases as long as the recipient can meet the requirements and provide the necessary proof. Medicaid recipients who need to get a lift chair will need to obtain a letter from their physician that states that the patient needs the lift chair to be able to stand or sit. If the patient is unable to stand or sit without the help of a lift chair, they are likely to receive coverage for the cost of the lift chair. However, if the patient also has a scooter, wheelchair, or power wheelchair, then they may not be eligible to receive coverage of this item. The Medicaid program dictates that the recipient must be able to walk, even with a walker or cane, before the cost of a lift chair can be covered.


Will Medicaid Pay for 24-Hour Home Care?

Yes, Medicaid will cover 24-hour home care under certain conditions. The patient requiring the care must receive an examination for a physician, physician’s assistant, or nurse practitioner that proves the need for 24-hour care. Plus, under the Consumer Directed Personal Assistance Program (CDPAP), patients are able to choose family members or friends to be their personal caregivers. CDPAP caregivers receive payment for their time spent caring for patients (who can be their loved ones), which adds extra benefit to receiving Medicaid coverage. Under this program, patients can have their home care costs covered and receive care from a familiar face, while loved ones of the patient receive reimbursement for their time.


How Long Will Medicaid Pay for Rehab?

New York Medicaid covers all rehabilitation services, as well as behavioral health therapy and detox treatments. The patient wishing to receive coverage for rehabilitation must submit a written order from a physician, physician’s assistant, or a nurse practitioner that states why the patient needs the requested services. It is important to keep in mind that Medicaid only covers rehabilitation services when they are provided by an authorized center that accepts Medicaid insurance coverage as a form of payment.


Medicaid will pay for rehabilitation services for a variable amount of time, depending on the circumstances. In-patient and out-patient rehabilitation services are covered for different amounts of time. In addition, there is a set period of time in which patients may receive coverage for rehabilitation. Check with your local Medicaid office for details regarding your personal situation and the coverage you might be eligible to receive.


Will Medicaid Pay for Braces?

Children who are recipients of Medicaid in New York are all entitled to receive free braces if their situation meets the guidelines. A dentist can provide an examination to determine if a child’s situation meets the requirements that would make them eligible to receive free braces covered by Medicaid. Generally, Medicaid will pay for braces if the individual is under age 21. Some of the conditions that qualify a child to receive free braces include:


· Cleft palate

· Issues with eating or chewing normally

· Impacted and/or erupted teeth

· Missing teeth (due to hereditary conditions)

· Serious underbites, overbites, and crossbites

· Trouble opening or using the mouth

· Speech impediments caused by tooth and/or jaw problems


Will Medicaid Pay for Dental Implants?

Medicaid covers the cost of medically necessary dental implants. However, before the Medicaid recipient will be able to receive coverage, they will need to submit a request for coverage that includes a letter from their physician and from their dentist explaining the reason and essential nature of the dental implants. Examples of when coverage of dental implants may be authorized by Medicaid include:


· Crown lengthening

· Full or partial dentures (as well as their replacement within a certain time period)

· Some cosmetic procedures

· Fixed bridgework (except cleft palate stabilization)

· Molar root canal therapy (for individuals over 21 years of age)

· Experimental procedures