Frequently Asked Questions (FAQs) about NY Medicaid Benefits

General Information

Q. What is the difference between Medicaid and Medicare?

A. Medicaid provides health coverage to eligible low-income adults, children, pregnant individuals, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.

Medicare is a federal health insurance program for people:

  • age 65 or older,
  • under age 65 with certain disabilities, and/or
  • any age with End-Stage Renal Disease/ESRD (permanent kidney failure requiring dialysis or a kidney transplant) or Amyotrophic Lateral Sclerosis/ALS.
Q. How do I order a new benefit card?

A. If your Medicaid is with your Local Department of Social Service (LDSS), to order a new Medicaid Benefit Identification Card, please call or visit your LDSS.

If your Medicaid is with the Marketplace (NY State of Health) and you need to order a new benefit card please call the call center at 1 (855) 355-5777.

Members residing in the five boroughs of New York City (NYC) can call the Human Resources Administration (HRA) Infoline at 1 (718) 557-1399 or the HRA Medicaid Helpline at 1(888) 692-6116.

Q. How often do I have to renew?

Most renewals are on an annual basis and Medicaid will send you a notice when it is time to renew.

If your Medicaid is with your Local Department of Social Service (LDSS), you will receive a renewal packet by mail prior to your renewal date. Your packet will let you know if there are other methods available to you for recertification, such as phone or internet renewal.

If your Medicaid is with NY State of Health, many renewals are handled administratively by Medicaid and no action is required. Should action be required on your part, you will be notified. In order to continue Medicaid without gaps in coverage, you must take action and provide documentation when requested.

Please Note: Medicaid mail cannot be forwarded. This means that if you changed your address at the post office and not with the Medicaid office, you will not receive your Medicaid mail. You must notify your Medicaid office of all address changes to ensure you receive any notices sent by them.

Q. How do I find my local Medicaid office?

A.Your local Medicaid office can be found at your Local Department of Social Service (LDSS). A listing of LDSS offices by county can be found here.

If you live in the five boroughs of New York City, your offices are run by the Human Resources Administration (HRA). A listing of offices can be found here.

Q. What do I have to do if I move from one county to another?

A. If your Medicaid is with your Local Department of Social Services, it is important to notify your Medicaid office any time you move, especially when you are moving to another county. Your original county needs to notify the new county and get your case transferred.

If you are currently enrolled in a managed care plan that is not offered in the new county, your local department of social services will notify you so that you can choose a new plan.

If your Medicaid is with the Marketplace, (NY State of Health), it is important that you update your account with your new address.

Q. How do I obtain Medicaid payment records, whether by request or by subpoena?

A. Information on how to request Medicaid payment records can be found at the link below:

Q. How do I report Medicaid fraud?

A. You can report Medicaid fraud by calling the Fraud Hotline 1-877-873-7283 or by filing a complaint online with the Office of the Medicaid Inspector General (OMIG) here.

Coverage and Benefits

Q. What health services are covered by Medicaid?

A. In general, the following services are paid for by Medicaid, but some may not be covered for you because of your age, financial circumstances, family situation, transfer of resource requirements, or living arrangements. Some services have small co-payments. These services may be provided using your Medicaid card or through your managed care plan if you are enrolled in managed care. You will not have a co-pay if you are in a managed care plan.

  • smoking cessation agents
  • treatment and preventive health and dental care (doctors and dentists)
  • hospital inpatient and outpatient services
  • laboratory and X-ray services
  • care in a nursing home
  • care through home health agencies and personal care
  • treatment in psychiatric hospitals (for persons under 21 or those 65 and older), mental health facilities, and facilities for the mentally retarded or the developmentally disabled
  • family planning and other reproductive health services
  • early periodic screening, diagnosis, and treatment for children under 21 years of age under the Child/Teen Health Program
  • medicine, supplies, medical equipment, and appliances (wheelchairs, etc.)
  • clinic services
  • transportation to medical appointments, including public transportation and car mileage
  • emergency ambulance transportation to a hospital
  • prenatal care
  • vision care and eyeglasses
  • some insurance and Medicare premiums
  • other health services

If you are eligible for Medicaid, you will receive a Benefit Identification Card which must be used when you need medical services. There may be limitations on certain services.

For you to use your Benefit Identification Card for certain medical supplies, equipment, or services (e.g., wheelchair, orthopedic shoes, transportation), you or the person or facility that will provide the service must receive approval before the service can be provided (prior approval).

Q. Can I get reimbursed for bills I paid for?

A. We may be able to pay you for some bills you paid before you asked for Medicaid. You can be paid for bills you paid before you asked for Medicaid and for bills you pay until you get your Medicaid card. Bills you paid before you asked for Medicaid must be for services you received on or after the first day of the third month before the month that you asked for Medicaid. For example, if you ask for Medicaid on March 11th, we may be able to pay you for services you received and paid for from December 1st until you get your Medicaid card.

We can pay you for some bills even if the doctor or other provider you paid does not take Medicaid, even if you paid the bills before you asked for Medicaid. After the day you ask for Medicaid, we can pay you only if the doctor or other provider takes Medicaid.

Always ask the doctor or other provider if he or she takes Medicaid. After you ask for Medicaid, we will not pay you if the doctor or other provider does not take Medicaid.

There are a few more rules:

  • The bills you paid must be for services that the Medicaid program pays for. These services include, but are not limited to, doctors, home care, hospitals and drugs.
  • We may only be able to pay what Medicaid pays for the services. This may be less than the bill you paid.
  • We can pay you only when we decide you can get Medicaid and only if you could have gotten Medicaid when you paid the bill.
  • We can pay you only when the bills you paid were for services that you needed.
  • You must give us the bills and prove that you paid them.
Will I have to pay co-payments?

A. The following services are subject to a co-payment:

  • Clinic Visits (Hospital-Based and Free-Standing Article 28 Health Department-certified facilities) - $3.00; NOTE: Effective 10/1/2023, clinic visits which include a vaccine administration as recommended by the Advisory Committee on Immunization Practices (ACIP) are co-pay exempt.
  • Laboratory Tests performed by an independent clinical laboratory or any hospital-based/free standing clinic laboratory - $0.50 per procedure;
  • Medical Supplies including syringes, bandages, gloves, sterile irrigation solutions, incontinence pads, ostomy bags, heating pads, hearing aid batteries, nutritional supplements, etc. - $1.00 per claim;
  • Inpatient Hospital Stays (involving at least one overnight stay; is due upon discharge) - $25.00;
  • Emergency Room - for non-urgent or non-emergency services - $3.00 per visit;
  • Pharmacy Prescription Drugs - $3.00 Brand Name Non-Preferred, $1.00 Brand Name Preferred, $1.00 Brand When Less Than Generic, $1.00 Generic;
  • Non-Prescription (over the counter) Drugs - $0.50.

There is no co-payment on private practicing physician services (including laboratory and/or x-ray services, home health services, personal care services or long term home health care services).

Co-pay Maximum

You are responsible to pay a maximum of up to $50 in a co-pay per quarter. The co-pay maximum is $200 per year and your year begins on April 1st and ends March 31st each year. If you reach your maximum of $50 in a quarter, a letter will be sent to you exempting you from paying any additional Medicaid co-payments for the remainder of that quarter.

Co-pay Exemptions

The following are exempt from all Medicaid co-payments:

  • Children under 21.
  • Pregnant members, during pregnancy and for the two months after the month in which their pregnancy ends
  • Family planning (birth control) services - this includes family planning drugs or supplies like birth control pills and condoms.
  • Residents of an Adult Care Facility licensed by the New York State Department of Health.
  • Residents of a Nursing Home.
  • Residents of an Office of Mental Health (OMH) or Office for People with Developmental Disabilities (OPWDD) certified Community Residence.
  • Enrollees in a Comprehensive Medical Case Management (CMCM) or Services Coordination Program.
  • Enrollees in the Home and Community Based Services (HCBS) or Traumatic Brain Injury (TBI) waiver programs.
  • Psychotropic and Tuberculosis drugs.
  • Members with incomes below 100 percent of the federal poverty level.
  • Members in Hospice.
  • American Indians and Alaska Natives who have ever received a service from the Indian Health Service, tribal health programs or under contract health services referral.
  • Effective 10/1/2023, adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and their administration.

You cannot be denied care or services because of your inability to pay a co-payment. A provider has the right to ask you for the co-payment at each visit and bill you for any unpaid co-payments.

Q. Where can I find information on the Medicare Part D Prescription Drug Program?

A. Information can be found on the Medicare Part D Prescription Drug Program webpage.

Pregnancy

Q. What health services are covered by Medicaid?

A. In general, the following services are paid for by Medicaid, but some may not be covered for you because of your age, financial circumstances, family situation, transfer of resource requirements, or living arrangements. Some services have small co-payments. These services may be provided using your Medicaid card or through your managed care plan if you are enrolled in managed care. You will not have a co-pay if you are in a managed care plan, except for pharmacy services, where a small co-pay will be applied.

  • smoking cessation agents
  • treatment and preventive health and dental care (doctors and dentists)
  • hospital inpatient and outpatient services
  • laboratory and X-ray services
  • care in a nursing home
  • care through home health agencies and personal care
  • treatment in psychiatric hospitals (for persons under 21 or those 65 and older), mental health facilities, and facilities for the mentally retarded or the developmentally disabled
  • family planning and other reproductive health services
  • early periodic screening, diagnosis, and treatment for children under 21 years of age under the Child/Teen Health Program
  • medicine, supplies, medical equipment, and appliances (wheelchairs, etc.)
  • clinic services
  • transportation to medical appointments, including public transportation and car mileage
  • emergency ambulance transportation to a hospital
  • prenatal care
  • vision care and eyeglasses
  • some insurance and Medicare premiums
  • other health services

If you are eligible for Medicaid, you will receive a Benefit Identification Card which must be used when you need medical services. There may be limitations on certain services.

For you to use your Benefit Identification Card for certain medical supplies, equipment, or services (e.g., wheelchair, orthopedic shoes, transportation), you or the person or facility that will provide the service must receive approval before the service can be provided (prior approval).

Will I have to pay co-payments?

A. The following services are subject to a co-payment:

  • Clinic Visits (Hospital-Based and Free-Standing Article 28 Health Department-certified facilities) - $3.00;
  • Laboratory Tests performed by an independent clinical laboratory or any hospital-based/free standing clinic laboratory - $0.50 per procedure;
  • Medical Supplies including syringes, bandages, gloves, sterile irrigation solutions, incontinence pads, ostomy bags, heating pads, hearing aid batteries, nutritional supplements, etc. - $1.00 per claim;
  • Inpatient Hospital Stays (involving at least one overnight stay; is due upon discharge) - $25.00;
  • Emergency Room - for non-urgent or non-emergency services - $3.00 per visit;
  • Pharmacy Prescription Drugs - $3.00 Brand Name Non-Preferred, $1.00 Brand Name Preferred, $1.00 Brand When Less Than Generic, $1.00 Generic;
  • Non-Prescription (over the counter) Drugs - $0.50.

There is no co-payment on private practicing physician services (including laboratory and/or x-ray services, home health services, personal care services or long term home health care services).

Co-pay Maximum

You are responsible to pay a maximum of up to $50 in a co-pay per quarter. The co-pay maximum is $200 per year and your year begins on April 1st and ends March 31st each year. If you reach your maximum of $50 in a quarter, a letter will be sent to you exempting you from paying any additional Medicaid co-payments for the remainder of that quarter.

Co-pay Exemptions

The following are exempt from all Medicaid co-payments:

  • Children under 21.
  • Pregnant members, during pregnancy and for the two months after the month in which their pregnancy ends
  • Family planning (birth control) services - this includes family planning drugs or supplies like birth control pills and condoms.
  • Residents of an Adult Care Facility licensed by the New York State Department of Health.
  • Residents of a Nursing Home.
  • Residents of an Office of Mental Health (OMH) or Office for People with Developmental Disabilities (OPWDD) certified Community Residence.
  • Enrollees in a Comprehensive Medical Case Management (CMCM) or Services Coordination Program.
  • Enrollees in the Home and Community Based Services (HCBS) or Traumatic Brain Injury (TBI) waiver programs.
  • Psychotropic and Tuberculosis drugs.
  • Members with incomes below 100 percent of the federal poverty level.
  • Members in Hospice.
  • American Indians and Alaska Natives who have ever received a service from the Indian Health Service, tribal health programs or under contract health services referral.

You cannot be denied care or services because of your inability to pay a co-payment. A provider has the right to ask you for the co-payment at each visit and bill you for any unpaid co-payments.

Q. I´m pregnant, how do I get a card for my baby?

A. To request a card for your unborn baby, you will need to contact your local department of social services or if your case is with the Marketplace, (NY State or Health), at 1 (855) 355-5777 and notify them that you are pregnant and what your anticipated due date is.

Those living in the five boroughs of NYC, whose cases are administered by the Human Resources Administration (HRA) office can call the HRA Infoline at 1 (718) 557-1399 or the HRA Medicaid Helpline at 1(888) 692-6116.

Once the Medicaid office receives the letter, they will issue you an unborn/infant card which you will use to take the baby to the doctor once they are born, until the child´s permanent card is issued.

Medicaid Managed Care

Q. What is a Medicaid Managed Care program?

A. A Medicaid Managed Care health plan will provide your care by working with a group (network) of doctors, clinics, and hospitals. You will choose one of the doctors from the health plan to be your Primary Care Provider (PCP). Your PCP will provide most of your care. You will need a referral from your PCP to see a specialist and for other services.

Q. What does managed care cover?

A. Managed care covers most of the benefits recipients will use, including all preventive and primary care, 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.

Q. Do I have to join a managed care plan?

A. In many counties you can join a plan if there is one available and you want to. However, there are some counties where families will have to join a plan. In these counties there are some individuals who don´t have to join. Please check with your local social services department to see if you have to join a plan.

Tax Information

Q. What is a Form 1095-B from the NYS Department of Health?

A. Form 1095-B is available by request for consumers who, were enrolled in Medicaid, Child Health Plus, or the Essential Plan (EP) during the past year. A separate form will be available for each Medicaid, Child Health Plus and EP consumer, even if multiple children are on the same Child Health Plus policy. These forms are only provided upon request. Please contact NY State of Health to request a Form 1095-B.

  • Phone: (800) 541-2831
  • E-mail: 1095B@health.ny.gov
  • Mail: NY State of Health P.O. Box 11774, Albany, NY 12211
Q. What do I need to do with Form 1095-B from the NYS Department of Health?

A. If you would like a copy of your Form 1095-B for your records, you can contact NY State of Health at (800) 541-2831 or via email at 1095B@health.ny.gov. You may also make the request by mail at: NY State of Health P.O. Box 11774, Albany, NY 12211

This document provides information to verify coverage provided by Medicaid, Child Health Plus, or the Essential Plan. You do not need to attach Form 1095-B to your federal income tax return. To determine whether you are required to file a federal income tax return, be sure to check with the IRS at their website, www.irs.gov.

Q. When will I receive my Form 1095-B from the NYS Department of Health?

A. The NYS Department of Health will only mail Form 1095-B to consumers upon request. Please contact NY State of Health at (800) 541-2831 or via email at 1095B@health.ny.gov. You may also make the request by mail at: NY State of Health P.O. Box 11774, Albany, NY 12211

Emergency Medical Conditions

Q. What is an Emergency Medical Condition?

A. The term "Emergency Medical Condition" is defined as a medical condition (including emergency labor and delivery) that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

  • Placing the patient's health in serious jeopardy;
  • Serious impairment to bodily function; or
  • Serious dysfunction of any bodily organ or part.

Care and services related to an organ transplant procedure are not included in this definition.

This definition must be met, after sudden onset of the medical condition, at the time the medical service is provided, or it will not be considered an emergency medical condition and therefore, cannot be covered by Medicaid.

Not all services that are medically necessary meet the definition of an emergency medical condition. Emergency medical conditions do not include debilitating conditions (e.g., heart disease or other medical conditions requiring rehabilitation) resulting from the initial event which later requires ongoing regimented care. The potentially fatal consequence of discontinuing Medicaid covered care, even if such care is medically necessary, does not transform the condition into an emergency medical condition.

Q. What is Medicaid for the treatment of an "Emergency Medical Condition"?

A. Medicaid payment is provided for care and services necessary for the treatment of an emergency medical condition, to certain temporary non-immigrants (e.g., certain foreign students, visitors/tourists) who are otherwise eligible and undocumented non-citizens. An undocumented non-citizen must meet all eligibility requirements, including proof of identity, income, and State residency to be eligible for Medicaid coverage of an emergency medical condition. Temporary non-immigrants, who have been allowed to enter the United States temporarily for a specific purpose and for a specified period of time, do not have to meet the State residency requirement to receive coverage for the treatment of an emergency medical condition and are considered "Where Found" for District of Fiscal Responsibility purposes.

Q. Who can receive Medicaid for the treatment of an emergency medical condition?

A. The following individuals may be eligible to recieve Medicaid for the treatment of an Emergency Medicaid Condition:

  • Undocumented Non-Citizen: An individual who is not lawfully present is considered undocumented if they entered the United States in a manner or in a place so as to avoid inspection or was admitted on a temporary basis and the period of authorized stay has expired. Undocumented individuals will not have valid/unexpired immigration documents.
  • Temporary Non-Immigrant: Non-immigrants are lawfully admitted to the U.S. temporarily for a specific purpose and for a specified period of time. Otherwise eligible non-immigrants, who are not New York State residents and who require immediate medical care may receive Medicaid coverage for the treatment of an emergency medical condition. Such temporary non-immigrants may receive this coverage, provided they did not enter the State for the purpose of obtaining medical care (e.g. with a medical visa).
    Temporary non-immigrants who are New York State residents (e.g., own or rent a home, work in New York State) may be eligible for Essential Plan (EP) or Medicaid, if otherwise eligible. These non-immigrants are given the New York State residency review. If they "pass" residency review, they may be eligible for either EP or full Medicaid.
Q. What services do not meet the definition of an emergency medical condition?

A. Certain types of care provided to chronically ill persons are beyond the intent of the federal and State laws and are not considered "emergency services" for the purpose of payment by Medicaid. Such care includes:

  • Alternate level of care in a hospital;
  • Nursing facility services, home care (including but not limited to personal care services, home health services and private duty nursing); and
  • Rehabilitation services (including physical, speech and occupational therapies).

The above-mentioned services do not fall within the definition of an emergency medical condition. Therefore, Medicaid does not cover the cost for the above-mentioned services or transportation to these services.

Q. How long is Medicaid coverage for the treatment of an emergency medical condition?

A. The initial authorization period for the treatment of an emergency medical condition may be up to a maximum of 15 months: three months retroactive coverage from the application date and 12 months prospective coverage from the application date. The authorization period may be from the first day of the third month prior to the month of application to the last day of the twelfth month prospectively.

Although a new Medicaid application is not required for later emergencies occurring within the established 12- month authorization, the Medicaid claim must indicate that it is for an emergency. The treating physician will determine if the medical conditions meet the definition of an emergency medical condition.

Other Topics

Q. What is a "Community Spouse"?

A. A "community spouse" is someone whose spouse is currently institutionalized or living in a nursing home. The community spouse is the member of the couple not currently living in a nursing home and whom usually resides at the couple´s home.

Q. I am a community spouse. Will I be allowed to keep any income or resources?

A. If your spouse is institutionalized or living in a nursing home, you will be permitted to keep some income known as a minimum monthly maintenance needs allowance (MMMNA). If you are currently receiving income in excess of the minimum monthly maintenance needs allowance, you may be asked to contribute twenty-five percent (25%) of the excess income to the cost of care for the institution

Q. What is the Medicaid Buy-In Program for Working People with Disabilities?

A. More informtion can be found on the program page here: Medicaid Buy-In Program