Continuing The Medicaid Eligibility Modernization

Welcome to the New York State (NYS) Department of Health, Office of Health Insurance Programs (OHIP), web page for the continuing modernization of New York's Medicaid eligibility and enrollment system in NY State of Health. This page provides information on the modernization effort for Medicaid enrollees who receive their Medicaid coverage through local departments of social services (LDSS). This page will be updated regularly.

NY State of Health, New York's integrated health insurance Marketplace, began covering most children and adults under the age of 65 in Medicaid in 2014.

Today, there are over 6 million people using the Marketplace. Now, as part of the multi-year effort to further modernize the technology and administration of the NYS Medicaid program, even more New Yorkers are receiving their Medicaid coverage through NY State of Health. They include enrollees who:

  • are dual-eligible (meaning they are eligible for Medicaid and Medicare), and/or
  • are over the age of 65 not seeking long-term care services, and/or
  • are applying for the Medicare Savings Program

All other populations who have been working with their Local Department of Social Service (LDSS) will continue to do so. Examples of enrollees who may rely on their LDSS for their Medicaid coverage include:

  • Individuals who receive cash assistance benefits like Supplemental Security Income (SSI) and Temporary Assistance for Needy Families (TANF);
  • Individuals seeking Community Based Long-Term Care; and/or
  • Individuals participating in the Medicaid Excess Income Program ("Spenddown program")

To find contact information for an LDSS, please visit this webpage

Transformation of New York's Medicaid eligibility and enrollment systems is a multi-year effort to further modernize the technology and administration of the NYS Medicaid program with a consumer-centric approach. The expectation is that this investment in the systems and processes that enable Medicaid administration in New York will improve the consumer experience and reshape how the State cares for New Yorkers. The primary objective of this continuing modernization is to create a user-friendly experience that provides personalized, compassionate support when helping consumers understand, receive, pay for, and make critical decisions around health care services.

The Office of Health Insurance Programs (OHIP), which administers the NYS Medicaid program, will aim to complete two sub-transformations within the overarching eligibility and enrollment system modernization.

The two sub-transformations are as follows:

  1. Non-MAGI Medicaid Population Migration, moving the Non-MAGI Medicaid population1 to a modern system.
  2. Appeals, creating a singular, centralized eligibility hearings and appeals system to simplify processes and improve how the NYS Department of Health distributes appeal decisions for its health insurance programs.

"Non-MAGI" refers to those who receive and rely on their Medicaid coverage through their Local Department of Social Service (LDSS), as outlined above. Non-MAGI populations may also include individuals with breast or cervical cancer, individuals in a medical facility, and/or individuals needing intermediate care for intellectual disabilities.1

The mission of continuing the modernization of the NYS Medicaid eligibility and enrollment system is to improve the quality of the health care system, make access to coverage more equitable, and enable OHIP to address the future health care needs of New Yorkers. The objectives of the continuing modernization include:

  1. A Consumer-Centric Design A business transformation that provides personalized, compassionate support when helping consumers understand, receive, pay for, and make critical decisions about health care services.
  2. Centralized Model: A transition to a centrally administered model to capitalize on the successful administration and transition of the MAGI population to NY State of Health.
  3. Increased Efficiency: Use of modern digital systems that will allow Frontline workers in the local districts and State employees to spend more time meeting the needs of consumers by reducing time spent on administrative tasks.
  4. Modernized Infrastructure: A modern system that will be available for this and future DOH Information Technology (IT) projects.
  5. Automated Technology: Enabled to provide advanced data analytics and automated activities. The use of advanced data analytics ensures OHIP is meeting the health equity needs of a diverse population.
  6. Trusted Security Standards: Secure system processing of Medicaid consumer data including high levels of data privacy and protection.

The initial eligibility and enrollment system modernization began in 2023 and will continue through the next several years. During this time, OHIP will work with stakeholder audiences to facilitate a smooth transition. Preparations for the first wave of population migration are already underway.

The following list shows the major milestones which are planned for the continuing modernization as of July 2024:

  • January 2024 - August 2025: Continued refinement of the modern system and on-going engagement of stakeholder audiences through education, training, LDSS support, and other activities to prepare for a successful transition starting from Day One.
  • September 30th, 2025:The modern system launches with a limited number of users supporting a portion of the Medicaid population who:
    • are dual-eligible (meaning they are eligible for Medicaid and Medicare), and/or
    • are over the age of 65 not seeking long-term care services, and/or
    • are applying for the Medicare Savings Program
    At this time, applications from consumers who fall into one of these categories will be taken through the NY State of Health Customer Service Center.
  • December 2025: Additional users will begin working in the modern system. Dual-eligible consumers and most consumers over the age of 65 will be able to apply for benefits and renew their coverage through the updated member portal.
  • 2026 and Beyond: Transition of the remaining Non-MAGI population, such as individuals with breast or cervical cancer, individuals in a medical facility, and individuals needing intermediate care for intellectual disabilities to the modern system.

The history of the continuing eligibility and enrollment system modernization includes both federal and state legislative directives and milestone events that took place to enact change for NYS Medicaid. The modernization effort started over a decade ago with the passing of the Affordable Care Act (ACA) in March 2010, which required accessible, consumer-centric systems for healthcare eligibility and enrollment. New York then passed legislation authorizing DOH to assume Medicaid administration from the counties. As a result, NYS was required to follow ACA requirements, which call for a new eligibility and enrollment system that is accessible, simple, technology enabled, and consumer-centric. In 2012, the NYS Assembly introduced a bill relating to the 6-year state administration of the local share of Medicaid from LDSS. This bill was the impetus for the overall NYS Medicaid modernization transformation.

The next major milestone marking NYS's administration of Medicaid was in 2014, when new Modified Adjusted Gross Income (MAGI) Medicaid enrollees began using NY State of Health, shortly after the Marketplace opened for public enrollment in 2013. In 2016, LDSS began to transition existing Medicaid consumers to NY State of Health.

In March 2020, the Families First Coronavirus Response Act (FFCRA) was signed into law, establishing the continuous coverage provision that the Consolidated Appropriations Act (CAA) ended.

More recently in 2022, federal guidance mandated NYS make changes to its renewal requirements and technology systems. The CAA institutes a CMS fine should states fail to comply with 2012 ACA requirements.

April 2023 marked the end of the continuous coverage as part of the federal omnibus bill that was enacted for the duration of the COVID-19 PHE that began in 2020. The unwind of the Public Health Emergency and the FY24 NYS Budget priorities created an opportunity for DOH leaders to convene and map out a vision to implement the future state of Medicaid.

Program Information

  1. I am currently receiving health care coverage. Will my coverage change?
    • No, the new system won't change your health care coverage.
  2. Will there be any interruptions in my health care coverage during the transition?
    • No, there will not be any interruption in your health care coverage during the transition.
  3. What are the expected benefits of the Continuing Eligibility Medicaid Modernization?
    • The Modernization will make it easier for you to get and use health care coverage. It will enable NY State of Health to better support New Yorkers’ health care needs in the future.

Support

  1. Where can I go to get help? Where or who can I ask questions about the Modernization?
    • If you have questions about the Modernization, please call the NY State of Health Customer Service Center.
  2. Am I still able to go to my local Department of Social Services or HRA for my Medicaid services since they currently offer support?
    • You can keep getting help the same way including at your local Department of Social Services or HRA.

News & Updates

For the latest news on the continuing modernization please see the following links:

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Questions and/or comments may be sent to: medicaid@health.ny.gov.