Top 10 FAQ on NY Medicaid | Fidelis Care

NY Medicaid | FAQs

Top 10 FAQ on New York Medicaid Plans

More than 7.5 million low-income New Yorkers have access to comprehensive health coverage through the Medicaid program in New York (as of January, 2022.) Depending on your age, financial condition, family situation, and living arrangements, Medicaid may be the optimal solution.

Use the resources below to learn more about your NY health insurance options, including eligibility for NYS Medicaid based on your income.

NY Medicaid:  Frequently asked questions on scope of coverage, eligibility, family planning and more.

1. What Is NY Medicaid?

Medicaid is a joint federal-state health care program for the disadvantaged. In New York, it offers free or low-cost medical treatment to:

  • Adults with low income
  • Low-income families and children
  • Individuals with disabilities
  • Certain senior citizens who use Medicare

Basic guidelines for the types of care you can receive through Medicaid and how much, if anything, you pay for it are set by the federal government. However, Medicaid benefits vary from state to state. States may provide additional services. Sometimes, individuals are required to contribute to the cost of their treatment, even though the identical services might be provided for free in another jurisdiction. There may also be further variations based on the circumstances of the individual.

Other unique initiatives are available in some states, such as New York, to assist low-income people who are not Medicaid eligible.Learn more about these options by contacting a New York State certified Medicaid representative here.

2. Can I Get Medicaid in New York?

The criteria used by each state to determine Medicaid eligibility vary. In the state of New York, you might qualify if:

  • You are disabled. Depending on your state, you might be able to access Medicaid regardless of your annual income. In certain places, Medicaid coverage is only available to those with disabilities whose income is below a certain threshold.
  • You are currently receiving Supplemental Security Income (SSI). Unless your state has stricter requirements, Medicaid eligibility is automatically granted if you are eligible for SSI. These states are frequently referred to as 209(b) states.
  • You are a low-income earner. Every state has its own set of regulations. To review New York's Medicaid program, click here.

To learn the precise income requirements, contact the Medicaid office in your state. Additionally, you can check online for eligibility by contacting a New York State certified Medicaid representative here.

3. What does Medicaid Cover in New York?

Every state's Medicaid program, including New York, must cover:

  • Contraceptive drugs and equipment
  • Treatment in rural, federally recognized health clinics
  • Care at qualified childbirth centers
  • Pediatrician or family nurse practitioner treatment
  • Early Periodic Screening, Diagnostic, and Treatment Services (EPSDT), which offers a variety of programs and services for kids and teenagers
  • Physician's fees (PCP)
  • Home health care services
  • Hospital inpatient and outpatient services
  • X-rays and lab analyses
  • Prenatal and postpartum care provided by nurses and midwives
  • Immunizations and preventative care for kids under 21
  • Quit-smoking or smoking cessation initiatives
  • Transporting patients to the hospital

More care is provided in many states, such as New York, including adult cancer screening tests, physical therapy, and occupational therapy.

Additionally, you can learn more about the full scope of coverage by contacting a New York State certified Medicaid representative here.

4. How Much is Medicaid in New York

For 2021, there is no monthly premium ($0) for families whose income is less than 1.6 times the poverty level. As of August 2022, this equates to ~$770 a week for a three-person family, ~$925 a week for a family of four. If under that amount, no monthly premium is required.

Consult the Child Health Plus eligibility tables below to see whether you would be required to pay a premium for coverage.

5. Do Women Have Access to Special Medicaid Programs in NY?

Yes, if you are low-income and have received a diagnosis of breast or cervical cancer through a NYS screening program. The Breast and Cervical Cancer Prevention and Treatment Program in your state can help you get medical care.

Pregnant women are typically covered by insurance, and Medicaid may be available to you even if your income is higher than that required to qualify for the program.

  • Learn more about Special Medicaid NY Programs here
6. Can I Get Medicaid and Medicare at the Same Time in NY?

Yes. Depending on your current situation, you can, in fact, have Medicaid and Medicare at the same time in New York State.

New York Medicare is a health insurance program for:

  • Individuals ages 65 and older
  • Individuals younger than age 65 who are disabled
  • Individuals with end-stage kidney disease

When you use Medicare, you must pay monthly premiums as well as other expenses like copays and deductibles. If you have Medicare and a low income, you might be eligible for Medicaid assistance to cover your Medicare expenses. 

  • You may hear people refer to you as being dual eligible if you have both Medicaid and Medicare.  Learn more about dual-coverage options by contacting a New York State certified Medicaid representative here.
  • To learn more about 2022 Dual Advantage Plans for Medicaid in NY, click here.  
7. How Long do Medicaid Benefits Last in NY?

Your Medicaid benefits in New York State are valid as long as you meet the eligibility requirements.

You must notify the IRS of any changes to your employment or address, often within 10 days. How these changes may impact your NY Medicaid coverage should be discussed with a representative at the Medicaid office.

Additionally, you can receive more details on benefit duration for NY Medicaid by contacting a New York State certified Medicaid representative here.

8. How can I Apply for NY Medicaid?

Applying for NY Medicaid (MMC) can be done in the following ways:

  • Contacting a New York State certified Medicaid representative by completing a contact form here.
  • Contacting a NYS Health insurance provider directly, by completing the form here.
  • By means of NY State of Health: The Official Health Plan Marketplace
  • Call 1-888-343-3547 to speak with a New York State certified Medicaid representative

Your NY Medicaid eligibility category will determine where you submit your application. Others may need to apply through their local Department of Social Service. Some individuals may apply through NY State of Health (LDSS). Representatives will assist in ensuring that you are able to apply in the appropriate area, regardless of where you begin.

9. How do I find a provider for NY Medicaid?

Use a 'Find-A-Doctor' Tool to find a local physician in New York who fits your personal plan.  This tool is an exceptional resource for members and prospective members interested in NY Health Insurance plans.

  • Can’t find the New York Provider you’re looking for?  Contacting a New York State certified Medicaid representative to help assist you in finding a Medicaid qualified provider in New York.
    • Complete the contact form here.
10. What is the NCCI Program for Medicaid?

A CMS program called the NCCI comprises of coding policies and changes. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes are used by providers to report procedures and services rendered to beneficiaries. Fiscal agents receive these codes along with claim forms for payment. The same provider performing the same service for the same beneficiary on the same day of service is addressed by NCCI regulations and edits.

To assure correct coding and reporting of services by doctors, this scheme was first introduced in the Medicare program in January 1996. The Current Procedural Terminology Manual of the American Medical Association, as well as federal, state, and local Medicare policies and modifications, serve as the foundation for NCCI's coding guidelines.

More on NCCI

  • To have New York State certified Medicaid representative explain NCCI in more detail, schedule a meeting by completing the form here.