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Medicaid in NYS

The Medicaid program is different for each state.  Each Medicaid recipient gets a permanent, plastic identification card that must be presented when services are required.  In New York State Medicaid pays doctors, hospitals, nursing homes, home care agencies and other providers directly, provided they have agreed to accept Medicaid clients and Medicaid payment as payment in full.  Medicaid will not pay for services of a provider who has not registered in the Medicaid program.

Providers are not required to participate in the Medicaid program.  If they do, they must accept all Medicaid recipients as patients.  Recipients, therefore, should be sure to find out in advance if a provider accepts Medicaid before obtaining treatment.  If the provider does not accept Medicaid, the recipient of services is personally liable for any part of the bill not covered by other insurance.

How to Apply for Medicaid
Medicaid, like all “means-tested” programs where eligibility is based on income and assets, requires extensive documentation to establish eligibility.  Proof is required to verify identity, residence, citizenship, disability (if the applicant is under 65 and is claiming to have a disability), marital status, income and resources and, in some cases, other information which may be necessary for an eligibility determination.

Examples of the kinds of documentation that may be submitted to verify the eligibility requirements are:

1) Personal identification

  • birth certificate
  • baptismal certificate
  • hospital certificate of birth
  • passport or immigration papers
  • current driver's license
  • Medicare card
2) Income statements for the last three months
Documentation must be submitted to verify all sources of earned and unearned income.  The applicant’s total monthly income will be compared against the Medicaid income standard to determine if the applicant has excess income.  Applicants with excess income are offered Medicaid under the Surplus Income Program. Examples of documents related to income include:
  • award letter from a benefits program
  • copy of check from benefits program
  • pay stubs showing earnings
  • bank statement of interest earned
3) Asset and Resource statements for the last 36 months
Medicaid requires all applicants to open their financial history to a review process.  The purpose of this audit is to allow the Medicaid program to see if the applicant has any  of unreported income or whether there are any large withdrawals that are not allowed by the Medicaid program. Examples of the types of documentation that must be submitted are:
  • savings bank books
  • checking statements
  • stock and bond certificates
  • life insurance policies
  • burial fund, burial plot, or funeral agreement deed to real property
4) Missing documentation (collateral investigation)
If the documents requested by the Medicaid agency are not obtainable, the applicant should present any substitute evidence available to establish eligibility.  Medicaid is jointly responsible with the applicant for exploring all factors concerning eligibility and should assist the applicant.

5) Verification of financial information
Medicaid can and will attempt to verify all financial information supplied by the Medicaid applicant.  The Medicaid program has access to Internal Revenue Service records and will use the applicant’s Social Security Number to find any unreported sources of income.  If Medicaid uncovers some source of funds, for example a bank account, which was not reported on the Medicaid application, an investigation will be opened. In New York City, the Investigations, Revenue, and Enforcement Administration of the Human Resources Administration handles the verification.

Medicaid Covered Services in New York State
New York State covers a wide range of medical services which can be grouped into three separate categories known as community Medicaid, home care, and institutional care.  A partial list of these services is provided below:

1. Community Services

  • services of physicians, dentists, nurses, optometrists, and other related professional personnel (podiatry services are available only to those individuals who are enrolled in the Medicare Savings program or who are also receiving Medicare coverage);
  • outpatient or clinic services;
  • sickroom supplies, eyeglasses, and prosthetic appliances;
  • physical therapy;
  • laboratory and X-ray services;
  • transportation when essential to obtain medical care; and
  • prescription drugs

2. Home Care Services

  • home health services such as nursing, physical therapy, occupational therapy, and home health aide;
  • personal care (home attendant) services; and
  • long term home healthcare program (“Lombardi” or “nursing home without walls”)
3. Institutional Services
  • care in hospitals, nursing homes, and other medical facilities.
NOTE:  Some services and supplies require prior approval for coverage and other services and supplies are covered only under certain conditions or limitations.

Information on Medicaid can be found on the website of the New York State Department of Health www.health.state.ny.us.  In New York City information on Medicaid can be obtained by calling
(718) 557-1399 or toll free (1-877-472-8411).