1. Medicaid Copay 2020
2. Waiving Copays For Medicaid Patients

Enhanced Care Plus is our state-sponsored Health and Recovery Plan, or HARP. A HARP plan provides Medicaid members with additional health care resources to help members take care of all their physical health, behavioral health, and non-medicaid support needs. The Centers for Medicare & Medicaid Services (CMS) has issued two new HCPCS codes for use by providers who are testing patients for COVID-19. Providers can submit these codes for dates of service on or after Feb. 4, 2020: U0001 – The CDC-developed test kit; U0002 – A laboratory test that is not the CDC-developed test kit (any technique).

1. You are responsible to pay a maximum of up to $200 in a co-pay year. Your year begins on April 1st and ends March 31st each year. If you reach your maximum of $200, a letter will be sent to you exempting you from paying Medicaid co-payments until April 1st. Co-pay Exemptions. The following are exempt from all Medicaid co-payments.
2. Individual Marketplace 2020 Flu Shot Incentive – A flu shot is an important part of maintaining your health. Receive a $100 Gift Card for each University of Utah Health Plans member who receives their flu shot between August 1 and December 31, 2020.
3. Medicaid is a joint federal-state health insurance program serving low-income individuals. How Working from Home in 2020 Affects Income Taxes.

INDIVIDUAL & FAMILY PLANS

Special Open Enrollment Period Happening Now – On January 28, President Biden signed an executive order opening Healthcare.gov for a special enrollment period (SEP) to help uninsured Americans get access to health care coverage. The SEP is from February 15, 2021 to August 15, 2021. Get A Quote >

Our plans are designed to cover essential health benefits including inpatient, outpatient, emergent, maternal, mental, behavioral, prescription drugs, lab tests, preventive, pediatric care services and much more.

Take control of your healthcare experience with our member benefits package. We can help you find the right doctor, access mental health services, find your secure medical information online, connect for a virtual visit, talk with a registered nurse or take advantage of your member discounts.

Individual Marketplace 2020 Flu Shot Incentive – A flu shot is an important part of maintaining your health. Receive a $100 Gift Card for each University of Utah Health Plans member who receives their flu shot between August 1 and December 31, 2020. Learn More >

On This Page

Member Benefits

ACCESS ASSISTANCE

Help finding & scheduling providers

TELEHEALTH

Care when and where
you need it most

NURSE LINE

24 Hours a day,
7 Days a Week

MEMBER PERKS

Additional benefits
& discounts

BEHAVIORAL HEALTH & CRISIS PREVENTION

You are not alone.

2021 On & Off Marketplace Benefit Highlights

DESCRIPTION	GOLD COPAY	SILVER 2300	SILVER COPAY	SILVER COPAY (OFF)	BRONZE 3 COPAY	BRONZE HSA	EXPANDED BRONZE	EXPANDED BRONZE HSA
FEATURES
Annual Deductible (individual/family)	$1,500/$3,000	$2,300/$4,600	$3,500/$7,000	$4,500/$9,000	$7,800/$15,600	$7,000/$14,000	$5,650/$11,300	$5,750/$11,500
Prescription Drug Deductible (individual/family)	$500/$1,000	$1,000/$2,000	$2,000/$4,000	Included with MD	Included with MD	Included with MD	$1,650/$3,300	Included with MD
Annual Out-of-Pocket Maximum (individual/family)	$7,000/$14,000	$8,300/$16,600	$8,000/$16,000	$8,150/$16,300	$8,550/$17,100	$7,000/$14,000	$8,550/$17,100	$7,000/$14,000
BENEFITS
Emergency and Urgent Care
Emergency Room	$200 copay AD	$600 copay AD	$500 copay AD	$500 copay AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Urgent Care	$25 copay DW	$35 copay DW	$30 copay DW	$30 copay DW	$45 copay/ first 3 visits then 40% AD	0% Co AD	$50 copay DW	$30 copay AD
Office Visits
Preventive Care/Screening/ Immunizations/Well-Child Visits/ Family Planning	No Charge
Primary Care	$25 copay DW	$35 copay DW	$30 copay DW	$30 copay DW	$45 copay/ first 3 visits then 40% AD	0% Co AD	$50 copay DW	$30 copay AD
Mental Health/Substance Abuse Services	$25 copay DW	$35 copay DW	$30 copay DW	$30 copay DW	$45 copay/ first 3 visits then 40% AD	0% Co AD	$50 copay DW	$30 copay AD
Specialty Care	$40 copay DW	$60 copay DW	$75 copay DW	$75 copay DW	40% Co AD	0% Co AD	$80 copay AD	$50 copay AD
Other Practitioner Care	$40 copay DW	$60 copay DW	$75 copay DW	$75 copay DW	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Habilitative Care	20% Co AD	$60 copay AD	40% Co AD	40% Co AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Rehabilitative Care	20% Co AD	$60 copay AD	40% Co AD	40% Co AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Vision Services
Adult Annual Routine Vision Exam	No Charge
Pediatric Vision Exam	No Charge
Corrective Lenses	No Charge					0% Co AD	No Charge	0% Co AD
Prescription Drugs
Formulary Generic Drugs	$15 copay DW	$15 copay DW	$15 copay DW	$15 copay DW	$30 copay DW	0% Co AD	$30 copay DW	35% Co AD
Formulary Preferred Brand Drugs	$30 copay DW	$30 copay DW	$30 copay DW	$30 copay DW	$45 copay DW	0% Co AD	$50 copay DW	35% Co AD
Formulary Non Preferred Brand Drugs	50% Co AD	25% Co AD	50% Co AD	50% Co AD	50% Co AD	0% Co AD	50% Co AD	35% Co AD
Specialty Drugs	25% Co AD	50% Co AD	25% Co AD	25% Co AD	40% Co AD	0% Co AD	25% Co AD	35% Co AD
Outpatient Hospital/Facility Services
Laboratory Services	20% Co AD	50% Co AD	40% Co AD	40% Co AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Radiology Services	20% Co AD	50% Co AD	40% Co AD	40% Co AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Specialized Scanning Services (CT, MRI, PET Scans)	20% Co AD	50% Co AD	40% Co AD	40% Co AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Medical / Surgical Services	20% Co AD	50% Co AD	40% Co AD	40% Co AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Inpatient Hospital Services
Medical/Surgical, Maternity Care, Mental Health, Substance Abuse, Skilled Nursing Care	20% Co AD	50% Co AD	40% Co AD	40% Co AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Hospice Care	20% Co AD	50% Co AD	40% Co AD	40% Co AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Transportation Assistance
Emergency Transportation - Ambulance	$250 copay/ trip AD	50% Co AD	$250 copay/ trip AD	$250 copay/ trip AD	40% Co AD	0% Co AD	50% Co AD	35% Co AD
Non-Emergency Medical and Non-Emergency Non-Medical Transportation to & from Medical Appointments	Not Covered
SUPPLEMENTAL BENEFITS
MD Live 24/7 Telehealth	No Charge					0% Co AD	No Charge	0% Co AD
Virtual Visits - Instant Online Care	No Charge					0% Co AD	No Charge	0% Co AD
24-Hour Nurse Line	No Charge
U Baby Care - Prenatal & Postnatal Care	No Charge
Tobacco Counseling, Smoking Cessation Program	No Charge

2021 Cost Sharing Reduction (CSR) Plans

CSR Plans available through Marketplace Only.

Plans available through Marketplace Only	SILVER COPAY 73% CSR	SILVER COPAY 87% CSR	SILVER COPAY 94% CSR	SILVER 2300 73% CSR	SILVER 2300 87% CSR	SILVER 2300 94% CSR
FEATURES
Annual Deductible (individual/family)	$3,000/$6,000	$400/$800	$0/$0	$2,300/$4,600	$400/$800	$0/$0
Prescription Drug Deductible (individual/family)	$500/$1,000	$150/$300	$0/$0	$500/$1,000	$200/$400	$0/$0
Annual Out-of-Pocket Maximum (individual/family)	$6,550/$13,100	$2,850/$5,700	$1,600/$3,200	$6,500/$13,000	$2,850/$5,700	$1,500/$3,000
BENEFITS
Emergency and Urgent Care
Emergency Room	$250 copay AD	$250 copay AD	$100 copay AD	$500 copay AD	$250 copay AD	$100 copay AD
Urgent Care	$30 copay DW	$10 copay DW	$10 copay DW	$30 copay DW	$20 copay DW	$10 copay DW
Office Visits
Preventive Care/Screening/ Immunizations/Well-Child Visits/ Family Planning	No Charge
Primary Care	$30 copay DW	$10 copay DW	$10 copay DW	$30 copay DW	$20 copay DW	$10 copay DW
Mental Health/Substance Abuse Services	$30 copay DW	$10 copay DW	$10 copay DW	$30 copay DW	$20 copay DW	$10 copay DW
Specialty Care	$60 copay DW	$30 copay DW	$20 copay DW	$60 copay DW	$35 copay DW	$15 copay DW
Other Practitioner Care	$60 copay DW	$30 copay DW	$20 copay DW	$60 copay DW	$35 copay DW	$15 copay DW
Habilitative Care	30% Co AD	25% Co AD	10% Co AD	$60 copay AD	$35 copay AD	$15 copay AD
Rehabilitative Care	30% Co AD	25% Co AD	10% Co AD	$60 copay AD	$35 copay AD	$15 copay AD
Vision Services
Adult Annual Routine Vision Exam	No Charge
Pediatric Vision Exam	No Charge
Corrective Lenses	No Charge
Prescription Drugs
Formulary Generic Drugs	$15 copay DW	$15 copay DW	$10 copay DW	$15 copay DW	$15 copay DW	$10 copay DW
Formulary Preferred Brand Drugs	$30 copay DW	$30 copay DW	$25 copay DW	$30 copay DW	$30 copay DW	$25 copay DW
Formulary Non Preferred Brand Drugs	50% Co AD	50% Co AD	50% Co AD	25% Co AD	15% Co AD	5% Co AD
Specialty Drugs	25% Co AD	20% Co AD	20% Co AD	50% Co AD	25% Co AD	15% Co AD
Outpatient Hospital/Facility Services
Laboratory Services	30% Co AD	25% Co AD	10% Co AD	50% Co AD	20% Co AD	10% Co AD
Radiology Services	30% Co AD	25% Co AD	10% Co AD	50% Co AD	20% Co AD	10% Co AD
Specialized Scanning Services (CT, MRI, PET Scans)	30% Co AD	25% Co AD	10% Co AD	50% Co AD	20% Co AD	10% Co AD
Medical / Surgical Services	30% Co AD	25% Co AD	10% Co AD	50% Co AD	20% Co AD	10% Co AD
Inpatient Hospital Services
Medical/Surgical, Maternity Care, Mental Health, Substance Abuse, Skilled Nursing Care	30% Co AD	25% Co AD	10% Co AD	50% Co AD	20% Co AD	10% Co AD
Hospice Care	30% Co AD	25% Co AD	10% Co AD	50% Co AD	20% Co AD	10% Co AD
Transportation Assistance
Emergency Transportation - Ambulance	$250 copay/trip AD	$250 copay/trip AD	$250 copay/trip AD	50% Co AD	50% Co AD	50% Co AD
Non-Emergency Medical and Non-Emergency Non-Medical Transportation to & from Medical Appointments	Not Covered
SUPPLEMENTAL BENEFITS
MD Live 24/7 Telehealth	No Charge
Virtual Visits - Instant Online Care	No Charge
24-Hour Nurse Line	No Charge
U Baby Care - Prenatal & Postnatal Care	No Charge
Tobacco Counseling, Smoking Cessation Program	No Charge

• COVID-19 News and Updates:
  • COVID Information for Medicaid Consumers:
    • Medicaid Coverage through Your Local Department of Social Services during the Coronavirus Emergency (Web) - (PDF)
    • Medicaid Telehealth Services During the Coronavirus Emergency (Web) - (PDF)

• IRS (Internal Revenue Service) Form 1095-B Update:
  • The 1095-B form for Tax Year 2020 is no longer being mailed automatically.
    If you need a copy of your 1095-B for Tax Year 2020, you can request it:
    • By Phone - call 1-800-541-2831 or
    • By e-mail - 1095B@health.ny.gov or
    • By mail - NY State of Health P.O. Box 11774 Albany, NY 12211
  Frequently Asked Questions about Form 1095-B - (Web) - (PDF)

Frequently Asked Questions (FAQs) for Current Medicaid Beneficiaries

What is a Community Spouse?

A community spouse is someone whose husband/wife is currently institutionalized or living in a nursing home. The community spouse is not currently living in a nursing home and usually resides at the couple´s home.

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

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

How do I find my local Medicaid office?

The Medicaid office is located in your local department of social services. A listing of offices can be located here: http://www.health.ny.gov/health_care/medicaid/ldss.htm

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: http://www1.nyc.gov/site/hra/locations/medicaid-locations.page

How do I order a new benefit card?

If your Medicaid is with your LDSS, to order a new Medicaid Benefit Identification Card, please call or visit your local department of social services.

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 NYC can call the HRA Infoline at 1 (718) 557-1399 or the HRA Medicaid Helpline at 1(888) 692-6116.

How often do I have to renew?

Most renewals are on an annual basis. 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.

Please note that 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.

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

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.

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

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 he/she is born, until the child´s permanent card is issued.

How do I report Medicaid fraud?

You can report Medicaid fraud by calling the Fraud Hotline 1-877-873-7283 or by filing a complaint online.

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

Should I apply for Medicare?

Medicaid provides health coverage to eligible low-income adults, children, pregnant women, 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,
• people under age 65 with certain disabilities, and
• people of all ages with End-Stage Renal Disease/ESRD (permanent kidney failure requiring dialysis or a kidney transplant) or Amyotrophic Lateral Sclerosis/ALS.

New Requirement for Medicaid Effective November 2017

If you are turning age 65 within the next three months or you are age 65 or older, you may be entitled to additional medical benefits through the Medicare program. You may be required to apply for Medicare as a condition of eligibility for Medicaid.

Medicare is a federal health insurance program for people age 65 and for certain people with disabilities, regardless of income. When a person has both Medicare and Medicaid, Medicare pays first and Medicaid pays second.

You are required to apply for Medicare if:

• You have Chronic Renal Failure (End-Stage Renal Disease/ESRD) or Amyotrophic Lateral Sclerosis (ALS); OR
• You are turning age 65 in the next three months or are already age 65 or older; AND your income is below 120% of the Federal Poverty Level (based on the household size for a single individual or married couple), or is at or below the applicable Medicaid Standard, then the Medicaid program will pay or reimburse you the cost of your Medicare premiums. If the Medicaid program can pay your premiums, you will be required to apply for Medicare as a condition of Medicaid eligibility.

If you have Medicaid and appear to be eligible for Medicare based on any of the criteria above, you must apply and show proof of Medicare application, or risk losing your Medicaid coverage.

When you apply for MEDICARE:

• Let the SSA representative know you are receiving or applying for Medicaid and you want to apply for MEDICARE. This allows you to enroll outside the MEDICARE open enrollment period.
• Before leaving the SSA office get a receipt or confirmation letter that you applied for MEDICARE.
• If the SSA agent tells you that you are not eligible to apply for MEDICARE then get a receipt or confirmation letter stating you tried to apply for MEDICARE but SSA said you are not eligible to apply for MEDICARE.

If you go to your local SSA office, you should bring:

• Proof of date of birth (e.g., copy of birth certificate, passport); and
• Proof of U.S. citizenship or lawful residence (e.g., passport, permanent resident card, work visa); and
• A copy of your Social Security card and your Medicaid card.

Proof of Medicare application can be:

• Copy of your red, white and blue Medicare Card
• Medicare Award Letter of Acceptance
• Medicare Application Submission Receipt
• Medicare Application Acknowledgment Letter
• Medicare Award Letter of Acceptance
• Medicare Letter of Denial

Apply Now:

• Social Security Administration 1-800-772-1213

Need help applying for MEDICARE?

If you have Medicaid and need help apply for MEDICARE the New York State Department of Health has contracted with several agencies that can help you. Contact one of our Facilitated Enrollers who can help you apply for MEDICARE. Facilitated Enrollers provide free, in person help in your community. To find a Facilitated Enroller near you, please see the list below of agencies, their contact phone number and the counties they serve.

LEAD AGENCY

SUBCONTRACTOR AGENCY	CONTACT PHONE NUMBER	COUNTIES SERVED
COMMUNITY SERVICE SOCIETY OF NY	ACR HEALTH	(315) 475-2430	Cayuga - Herkimer - Madison - Oneida - Onondaga - Oswego
	Coordinated Care Services Inc	(585) 613-7662	Livingston - Monroe
	Finger Lakes Community Health	(800) 346-2211	Chemung - Ontario - Schuyler - Seneca - Steuben - Wayne - Yates
	Healthy Capital District Initiative	(518) 462-1459	Albany - Saratoga - Schenectady - Schoharie
	Independent Living Center of the Hudson Valley	(518) 274-0701	Columbia - Green - Rensselaer
	Southern Adirondack Independent Living Center (SAIL)	(518) 792-3537	Fulton - Hamilton - Montgomery - Warren - Washington
	Southern Tier Independent Center	(607) 724-2111	Broome - Chenango - Cortland - Delaware - Otsego - Tioga - Tompkins
	Westchester Disabled on the Move	(914) 968-4717	Orange - Putnam - Rockland - Westchester
	Community Service Society (as provider of FE services)	(888) 614-5400	Dutchess - Sullivan - Ulster
SUFFOLK COUNTY DEPARTMENT OF SOCIAL SERVICES	Nassau-Suffolk Hospital Council	(631) 656-9783	Nassau - Suffolk
WESTERN NY INDEPENDENT LIVING INC.	Massena Independent Living Center	(315) 764-9442	Franklin - Jefferson - Lewis - St. Lawrence
	Southwestern Independent Living Center	(716) 661-3010	Chautauqua
	Western NY Independent Living (as provider of FE services)	(716) 836-0822	Allegany - Cattaraugus - Clinton - Erie - Essex - Genesee - Niagara - Orleans - Wyoming
PUBLIC HEALTH SOLUTIONS	Public Health Solutions (as provider of FE services)	1-800-517-6670	Bronx - Kings - New York - Queens - Richmond

If you send an e-mail tomedicaid@health.ny.gov please include your phone number so we can respond to you as quickly as possible.

Fact Sheets

What You Need to Know About:

Sickle Cell - April 2021

Smoking and How You Can Quit - March 2021

• English (PDF)
• Español (Spanish) (PDF)
• 繁體中文 (Traditional Chinese) (PDF)
• русский (Russian) (PDF)
• Kreyòl Ayisyen (Haitian Creole) (PDF)
• Bেঙলি (Bengali) (PDF)
• 한국어 (Korean) (PDF)

EVV and You - December 2020

• English (PDF)
• Español (Spanish) (PDF)
• 繁體中文 (Traditional Chinese) (PDF)
• русский (Russian) (PDF)
• Kreyòl Ayisyen (Haitian Creole) (PDF)
• Bেঙলি (Bengali) (PDF)
• 한국어 (Korean)

HIV, PrEP, and You - November 2020

• English (PDF)
• Español (Spanish) (PDF)
• 繁體中文 (Traditional Chinese) (PDF)
• русский (Russian) (PDF)
• Kreyòl Ayisyen (Haitian Creole) (PDF)
• Bেঙলি (Bengali) (PDF)
• 한국어 (Korean)

Asthma Control and You - November 2020

• English (PDF)
• Español (Spanish) (PDF)
• 繁體中文 (Traditional Chinese) (PDF)
• русский (Russian) (PDF)
• Kreyòl Ayisyen (Haitian Creole) (PDF)
• Bেঙলি (Bengali) (PDF)
• 한국어 (Korean)

Diabetes, Prevention, and You - October 2020

• English (PDF)
• Español (Spanish) (PDF)
• 繁體中文 (Traditional Chinese) (PDF)
• русский (Russian) (PDF)
• Kreyòl Ayisyen (Haitian Creole) (PDF)
• Bেঙলি (Bengali) (PDF)
• 한국어 (Korean)

High Blood Pressure, Prevention, and You - October 2020

• English (PDF)
• Español (Spanish) (PDF)
• 繁體中文 (Traditional Chinese) (PDF)
• русский (Russian) (PDF)
• Kreyòl Ayisyen (Haitian Creole) (PDF)
• Bেঙলি (Bengali) (PDF)
• 한국어 (Korean)

Medicaid Telehealth Services During the Coronavirus Emergency - May 2020

• Español (Spanish) (PDF)
• 繁體中文 (Traditional Chinese) (PDF)
• русский (Russian) (PDF)
• Kreyòl Ayisyen (Haitian Creole) (PDF)
• Bেঙলি (Bengali) (PDF)
• 한국어 (Korean)

The New Federal Public Charge Rule and Health Insurance - January 2020

• Español (Spanish)
• 繁體中文 (Traditional Chinese)
• 简体中文 (Simplified Chinese)
• русский (Russian)
• Kreyòl Ayisyen (Haitian Creole)
• Medicaid Coverage of Orthopedic Footwear and Compression Stockings - December 2013

General Medicaid FAQs

Important:
To go directly to 'What is the Effect of Trusts on Medicaid Eligibility?',
please click here.

Medicaid FAQs:

What is Medicaid?

Medicaid is a program for New Yorkers who can´t afford to pay for medical care.

What is the Medicaid State Plan?

How do I know if I qualify for Medicaid?

You may be covered by Medicaid if:

• You have high medical bills.
• You receive Supplemental Security Income (SSI).
• You meet certain financial requirements.

How do I apply for Medicaid?

You may apply for Medicaid in the following ways:

• NY State of Health, The Official Health Plan Marketplace (855) 355-5777
• Managed Care Organization (MCO)
• Medicaid Helpline (800) 541-2831

Where you apply for Medicaid will depend on your category. Your category might be single, childless couples, pregnant women, parent(s) and caretaker relatives with dependent children, elderly and/or disabled.

The Marketplace, (NY State of Health) determines eligibility using Modified Adjusted Gross Income (MAGI) Rules. In general, income is counted with the same rules as the Internal Revenue Service (IRS) with minor variations. Applications may be completed online, in person with a navigator or certified application counselor, by mail and by phone.

The following individuals should apply in the Marketplace, (NY State of Health):

• Adults (not pregnant) and aged 19-64, not eligible for Medicare;
• Pregnant Women and Infants;
• Children ages 1 - 18; and
• Parents and Caretaker Relatives

The following individuals should apply with their Local Department of Social Services (LDSS):

• Individuals age 65 and older, who are not parents or caretaker relatives, when age is a condition of eligibility;
• Individuals whose eligibility is based on being blind or disabled or who request coverage for community based long term care (CBLTC) services; including those individuals with an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS);
• Medicare Savings Program (MSP);
• Medicaid Buy-In for Working People with Disabilities enrollees (MBI-WPD);
• Former Foster Care youth;
• Residents of adult homes and nursing homes;
• Residential treatment center/community residences operated by The Office of Mental Health (OMH); and
• Presumptive Eligibility (PE) for Pregnant Women apply with provider, processed by the LDSS.

What do I need to apply for Medicaid?

The necessary documentation needed to apply for Medicaid will depend on your category, whether you fall under the Modified Adjusted Gross Income (MAGI) guidelines or non-MAGI guidelines which are defined in the following section.

MAGI Eligibility Groups include:

• Pregnant Women
• Infants and Children under age 19
• Childless Adults who are: not pregnant, age 19-64, not on Medicare, and could be certified disabled but not on Medicare
• Parents/Caretaker Relatives
• Family Planning Benefit Program
• Children in Foster Care (Chafee)

Non - MAGI Eligibility Groups include:

• Individuals who are age 65 or older, who are not a parent or caretaker relative, individuals who are blind or disabled who do not meet the criteria of any of the MAGI eligibility groups
• COBRA
• Medicare Savings Program (MSP)
• AIDS Health Insurance Program (AHIP)
• Medicaid Buy-In for Working People with Disabilities
• Medicaid Cancer Treatment Program
• Residents of Adult Home run by LDSS, OMH Residential Care Centers/Community Residences

Application for Non-MAGI

The following paper application may only be printed and completed if you are applying at a local department of social services (LDSS) for Medicaid because you are over the age of 65 or an individual in your household is deemed certified blind or disabled or you are applying for Medicaid with a spenddown.

If you are blind or visually impaired many of DOH´s forms are available in alternative format

Application

DOH-4220

• English, Spanish, Chinese, Haitian Creole, Italian, Korean, Russian
• You may be required to apply for Medicare as a condition of eligibility for Medicaid. Please read OHIP-0112 below for more information on who is required to apply for Medicare and how to apply.

DOH-5130 - Alternative Format Supplement - Options to receive information if you are blind or visually impaired.

• English, Spanish, Chinese, Haitian Creole, Italian, Korean, Russian

Supplement A

There are two Supplements: DOH-4495A and DOH-5178A. Please read the instructions below to see which Supplement you should use.

If you reside in a county outside of New York City, use Supplement DOH-5178A.

• DOH-5178A
  • English, Spanish, Chinese, Haitian Creole, Italian, Korean, Russian

If you reside in the five boroughs of New York City, use Supplement DOH-4495A.

• DOH-4495A:
  • English, Spanish, Chinese, Haitian Creole, Italian, Korean, Russian

How do I designate or change an authorized representative?

When you complete the Access NY Health Care application DOH-4220 you may assign a representative. You may allow them to apply for and/or renew Medicaid for you, discuss your Medicaid application or case and/or allow them to get notices and correspondence. If you would like to authorize or change a representative at renewal or anytime in between renewals, you may fill out DOH-5247 and submit this with your renewal. You can find this document here

If I have an immediate need for Personal Care Services or Consumer Directed Personal
Assistance Services, can I get my eligibility for these services processed more quickly?

• Immediate Need for Personal Care Services/Consumer Directed Personal Assistance Services: Informational Notice and Attestation Form (OHIP-0103).

If you think you have an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), you may have your eligibility for these services processed more quickly if you:

• have no voluntary informal caregivers able and willing to provide or continue to provide care;
• are not receiving needed assistance from a home care services agency;
• have no third party insurance or Medicare benefits available to pay for needed assistance; and
• have no adaptive or specialized equipment or supplies in use to meet, or that cannot meet, your need for assistance.

If you don´t have Medicaid coverage, you may ask to have your Medicaid application processed more quickly by sending in: a completed Access NY Health Insurance Application (DOH-4220); an **Access NY Supplement A (DOH-4495A)/(DOH-5178A), if needed; a physician´s order for services; and a signed 'Attestation of Immediate Need' (OHIP-0103) to your local department of social services.

If you already have Medicaid coverage that does not include coverage for community-based long term care services, you must send in an **Access NY Supplement A (DOH-4495A)/(DOH-5178A), if needed, a physician´s order for services and a signed 'Attestation of Immediate Need' (OHIP-0103) to your local department of social services.

If you already have Medicaid coverage that includes coverage for community-based long term care services, you must send in a physician´s order for services and a signed 'Attestation of Immediate Need' (OHIP-0103) to your local department of social services.

If you don´t already have Medicaid coverage or you have Medicaid coverage that does not include coverage for community-based long term care services: All of the required forms (see the appropriate list, above) must be sent in to your local social services office or, if you live in NYC, to the Human Resources Administration (HRA). As soon as possible after receiving all of these forms, the social services office/HRA will then check to make sure that you have sent in all the information necessary to determine your Medicaid eligibility. If more information is needed, they must send you a letter, by no later than four days after receiving these required forms, to request the missing information. This letter will tell you what documents or information you need to send in and the date by which you must send it. By no later than 7 days after the social service office/HRA receives the necessary information, they must let you know if you are eligible for Medicaid. By no later than 12 days after receiving all the necessary information, the social services office/HRA will also determine whether you could get PCS or CDPAS if you are found eligible for Medicaid. You cannot get this home care from Medicaid unless you are found eligible for Medicaid. If you are found eligible for Medicaid and PCS or CDPAS, the social services office/HRA will let you know and you will get the home care as quickly as possible.

If you already have Medicaid coverage that includes coverage for community-based long term care services: The physician´s order and the signed Attestation of Immediate Need must be sent to your local social services office or HRA. By no later than 12 days after receiving these required forms, the social services office/HRA will determine whether you can get PCS or CDPAS. If you are found eligible for PCS or CDPAS, the social services office/HRA will let you know and you will get the home care as quickly as possible.

**Note: Individuals with an immediate need for Personal Care Services or Consumer Directed Personal Assistance Services may attest to the current value of any real property and to the current dollar amount of any bank accounts.

If you qualify under a MAGI eligibility group, you will have to provide documents to verify eligibility if necessary.

• If you are applying for Medicaid through the Marketplace (NY State of Health), you may attest to your household income for the upcoming year. If your income is different than the income found on the data matches, income documentation may need to be provided.
• Citizenship/Immigration status and social security number will be verified through federal data sources. If citizenship/immigration status or social security number does not match, documentation must be provided.

If you qualify under a non-MAGI eligibility group, the following is a guide to the documentation that must be submitted to help determine eligibility

• If you are a U.S. citizen (born in the U.S. or one of its territories) and provide a valid Social Security Number (SSN), a match with the Social Security Administration (SSA) will verify your SSN, date of birth and U.S. citizenship. If SSA verifies this information, no further proof is needed. The SSA match cannot verify birth information for a naturalized citizen. You will need to submit proof of naturalization (e.g., Naturalization Certificate (N-550 or N-570) or a U.S. passport.
• Proof of citizenship or immigration status*
• Proof of age (if not verified by SSA), like a birth certificate
• Four weeks of recent paycheck stubs (if you are working)
• Proof of your income from sources like Social Security, Veteran´s Benefits (VA), retirement benefits, Unemployment Insurance Benefits (UIB), Child Support payments
• If you are age 65 or older, or certified blind or disabled, and applying for nursing home care waivered services, or other community based long term care services, you need to provide information on bank accounts, insurance policies and other resources
• Proof of where you live, such as a rent receipt, landlord statement, mortgage statement, or envelope from mail you received recently
• Insurance benefit card or the policy (if you have any other health insurance)
• Medicare Benefit Card (the red, white, and blue card)**

• *Note: Medicaid coverage is available, regardless of alien status, if you are pregnant or require treatment for an emergency medical condition and you meet all other Medicaid eligibility requirements.
• **Note: As a condition of eligibility for Medicaid, if you appear eligible for Medicare, you must apply and show proof of application.
  You are required to apply for Medicare if:
  • You have Chronic Renal Failure or Amyotrophic Lateral Sclerosis (ALS); OR
  • You are turning age 65 in the next three months or are already age 65 or older; AND your income is below 120% of the Federal Poverty Level (based on the household size for a single individual or married couple), or is at or below the applicable Medicaid Standard, then the Medicaid program will pay or reimburse you the cost of your Medicare premiums. If the Medicaid program can pay your premiums, you will be required to apply for Medicare as a condition of Medicaid eligibility.

  Proof of Medicare application can be:

  • Your award or denial letter from the Social Security Administration, OR
  • Your on-line confirmation letter stating that you have applied for Medicare with the Social Security Administration.

  Apply Now:

  • Social Security Administration 1-800-772-1213

If I think I am eligible for Medicaid, should I cancel any other health insurance I
might already have?

No. If you currently pay for health insurance or Medicare coverage or have the option of getting that coverage, but cannot afford the payment, Medicaid can pay the premiums under certain circumstances.

Even if you are not eligible for Medicaid benefits, the premiums can still be paid, in some instances, if you lose your job or have your work hours reduced. If you need help with a COBRA premium, you must apply quickly, to determine if Medicaid can help pay the premium.

You may be eligible for the Medicare Savings Program. This program pays your Medicare premiums and deductibles.

If you have Acquired Immune Deficiency Syndrome (AIDS), Medicaid may be able to help pay your health insurance premiums.

How do I know if my income and resources qualify me for Medicaid?

The chart below shows how much income you can receive in a month and the amount of resources (if applicable) you can retain and still qualify for Medicaid. The income and resource (if applicable) levels depend on the number of your family members who live with you.

2021 Income & Resource Levels*

Family Size

Medicaid Income Level for Single People & Couples without Children		Net Income for Families and Individuals who are Blind, Disabled or Age 65+		Resource Level (Individuals who are Blind, Disabled or Age 65+ ONLY)
Annual	Monthly	Annual	Monthly
1	$17,775	$1,482	$10,600	$884	$15,900
2	$24,040	$2,004	$15,600	$1,300	$23,400
3	$30,305	$2,526	$17,940	$1,495
4	$36,570	$3,048	$20,280	$1,690
5	$42,836	$3,570	$22,620	$1,885
6	$49,101	$4,092	$24,960	$2,080
7	$55,366	$4,614	$27,300	$2,275
8	$61,631	$5,136	$29,640	$2,470
9	$67,896	$5,658	$31,980	$2,665
10	$74,162	$6,181	$34,320	$2,860
For each additional person, add:	$6,266	$523	$2,340	$195

Effective January 1, 2021

Income and Resource Levels are subject to yearly adjustments.

You may also own a home, a car, and personal property and still be eligible. The income and resources (if applicable) of legally responsible relatives in the household will also be counted.

What is the Effect of Trusts on Medicaid Eligibility?

What is a Trust?

A trust is a legal instrument by which an individual gives control over his/her assets to another (the trustee) to disburse according to the instructions of the individual creating the trust. A trust can contain:

• Cash or other liquid assets; and
• Real or personal property that could be turned into cash.

What Things Count as Assets and are Used to Establish a Trust?

Assets often placed in trust include income, accumulated resources, and real property.

How Does a Trust Affect My Medicaid Benefits?

As a general rule, if you use your assets to establish a trust on or after January 1, 2000, all or part of the trust assets will be counted as your resource for purposes of determining your Medicaid eligibility.

• In the case of a revocable trust, the whole trust is your resource.
• In the case of an irrevocable trust, if there are any circumstances under which payment could be made to you or for your benefit, the portion of the trust from which payment could be made is your resource.

Are There Any Exceptions to These Counting Rules?

There are certain exceptions that apply to:

• 'Special needs trusts' (sometimes referred to as 'supplemental needs trusts') which are created for the benefit of a certified disabled person under the age of 65. A 'special needs trust' must:
  • be created with the individual´s own assets;
  • be created by the disabled person, by the disabled person´s parent, grandparent, or legal guardian, or by a court; and
  • include language specifying that upon the death of the disabled person, the state will receive all amounts remaining in the trust, up to the amount of Medicaid paid out on behalf of the individual; and
• 'Pooled trusts' which are created for the benefit of a certified disabled person of any age. To be considered a 'pooled trust':
  • the trust must be established and managed by a non-profit association;
  • the trust maintains separate accounts for each person whose assets are included in the pooled trust, but pools these accounts for purposes of investment and management of the trust funds;
  • the disabled individual´s account in the trust must be established by the disabled individual, by the disabled individual´s parent, grandparent or legal guardian, or by a court; and
  • the trust must include language specifying that upon the death of the individual, funds not retained by the non-profit organization will go to the state, up to the amount of Medicaid paid out on behalf of the individual.

Medicaid will not count the assets in a special needs trust or pooled trust if it meets the described criteria. Income directly diverted to one of these types of trusts or received and then placed into the trust is not counted as income. Verification that the income was placed into the trust is required. Any trust assets distributed to the disabled individual are counted as income.

How Do I Request that the Local Social Services District Rebudget My Income Once I have Created a Trust?

You must provide a copy of the trust to your local social services district. You must include a written statement indicating the amount of monthly income that will be placed into the trust each month.

How Does Money from a Trust that is Not My Resource Affect My Medicaid Benefits?

• Money paid directly to you from the trust is counted as income.
• Money paid directly to someone for your benefit will not count as income (e.g., food, shelter, telephone bills, education, entertainment, etc.).

How Can I Find Out More About Setting Up a Trust?

If you are interested in setting up a trust, you should consult a lawyer or financial advisor. You may be able to get a lawyer at no cost to you by calling your local Legal Aid or Legal Services Office. For the names of other lawyers, call your local or State Bar Association.

Note: Also, for married and single individuals, assets that you may use to fund a trust and which we may not count while you are living in the community, will count in determining the amount of income you must contribute toward the cost of long term nursing home care. Additional rules apply to transfers to and from trusts under the transfer of assets provisions.

If you are married and your Medicaid eligibility is determined under spousal impoverishment budgeting with post-eligibility rules (e.g. you are enrolled in a Medicaid Managed Long Term Care plan.), any of your income placed in a trust will count in determining your eligibility.

This Information is General.
For Questions Call 1-800-541-2831.

Can I be eligible for Medicaid even if I make more money than the chart shows?

Yes, some people can. Pregnant women, children, disabled persons, and others may be eligible for Medicaid if their income is above these levels and they have medical bills. Ask your Medicaid worker if you fit into one of these groups.

Click here for more information on the Medicaid Excess Income program.

Individuals who are certified blind, certified disabled, or age 65 or older who have more resources may also be eligible. Ask your Medicaid worker if this applies to you.

If an adult has too much income and/or resources and is not eligible for Medicaid, that person may be eligible for:

Expanded Income levels for Children and Pregnant Women

• Infants to age one and pregnant women - 223% of the federal poverty level.
• Children age 1 through 18 years - 154% of the federal poverty level.

Monthly Income Effective January 1, 2021^*

Number in Family	154% FPL**	223% FPL**
1	$1,653	$2,394
2	$2,236	$3,238
3	$2,819	$4,081
4	$3,401	$4,925
5	$3,984	$5,769
6	$4,567	$6,612
7	$5,149	$7,456
8	$5,732	$8,300
For each additional person, add:	$583	$844

• * Income Levels are subject to yearly adjustments.
• ** FPL = Federal Poverty Level

If a child has too much income and is not eligible for Medicaid, the child may be eligible for Child Health Plus.

Can I get reimbursed for bills I paid for?

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.

What is the Medicaid Excess Income Program?

How long does it take to get Medicaid?

Generally, a determination of eligibility must be done and a letter sent notifying you if your application has been accepted or denied within 45 days of the date of your application. If you are pregnant or applying on behalf of children, a determination should be made within 30 days from the date of your application. If you are applying and have a disability which must be evaluated, it can take up to 90 days to determine if you are eligible.

What are my rights?

What are my rights?

The Medicaid application, Access NY Health Care, tells you what your rights are when you apply for Medicaid. See the pages titled 'Terms, Rights and Responsibilities.' People who receive Medicaid have privacy rights. Medicaid keeps your health information private and shares it only when we need to.

If you are not satisfied with a decision made by the local social services district, you may request a conference with the agency. You may also appeal to the New York State Office of Temporary and Disability Assistance and request a Fair Hearing.

How do I request a State fair hearing?

If your eligibility decision was made at the Local Department of Social Services:

1) Telephone: You may call the state wide toll free number: 800-342-3334; OR

2) Fax Number: (518) 473-6735; OR

3) On-Line: Complete and send the online request form at: http://otda.ny.gov/programs/applications/; OR

4) Write: to the Fair Hearing Section, New York State Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York 12201.

In New York City you can also:

Bring a copy of this notice to the New York State Office of Temporary and Disability Assistance at:

• 14 Boerum Place, 1st Floor, Brooklyn, or
• 111 Livingston Street, 4th Floor, Brooklyn, NY 11201

If your eligibility decision was made by the Marketplace, (NY State of Health):

Online:www.nystateofhealth.ny.gov

Telephone: 1-855-355-5777

Fax: 1-855-900-5557

In writing:
New York State of Health
P.O. Box 11729
Albany, New York 12211

Please keep a copy of any notice for yourself

If your request involves any issues about health benefits or services provided under your Managed Care Plan or Managed Long Term Care you can write to:

NYS Office of Temporary and Disability Assistance
Office of Administrative Hearings
Managed Care Hearing Unit
P.O. Box 22023
Albany, New York 12201-2023

Fax: your copy of the notice, or your written request to 518 473-6735

Time limits to ask for a fair hearing or appeal - If you want to ask for a fair hearing or appeal, call right away because there are time limits. If you wait too long, you may not be able to get a fair hearing or appeal.

Will there be a lien (legal claim) placed on my estate (my assets) when I die?

If you receive medical services paid for by Medicaid on or after your 55th birthday, or when permanently residing in a medical institution, Medicaid may recover the amount of the cost of these services from the assets in your estate upon your death.

For individuals who received Medicaid under a MAGI eligibility group, the estate recovery is limited to the amount Medicaid paid for the cost of nursing facility services, home and community-based services, and related hospital and prescription drug services received on or after the individual’s 55th birthday.

What health services are covered by Medicaid?

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 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
• 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?

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 $200 in a co-pay year. Your year begins on April 1st and ends March 31st each year. If you reach your maximum of $200, a letter will be sent to you exempting you from paying Medicaid co-payments until April 1st.

Co-pay Exemptions

The following are exempt from all Medicaid co-payments:

• Children under 21.
• Pregnant women. (Pregnant women are exempt during pregnancy and for the two months after the month in which the 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.

What is a Medicaid managed care program?

A Medicaid Managed Care health plan will provide your care by working with a group (network) of doctors, clinics, hospitals and pharmacies. 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.

What does managed care cover?

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.

Do I have to join a managed care plan?

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.

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

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

Medicaid for the Treatment of an Emergency Medical Condition Fact Sheet

I just want Family Planning Benefits. How do I apply?

I want to know more about Child Health Plus.

Why did I receive a 1095-B tax form from New York State Department of Health, what
does it mean, and what do I do with it?

The Affordable Care Act (ACA) requires most Americans to have health coverage that meets Minimum Essential Coverage (MEC). Health coverage providers are required to report certain health benefit information to the Internal Revenue Service (IRS). The tax form you received, Form 1095-B, represents health coverage you received in Medicaid, Child Health Plus (CHP) or Essential Plan (EP) for part or all of the past year. New York State Department of Health reports the months you had MEC directly to the IRS on your behalf and sends you a copy of the 1095-B for your records. This form does not require any action on your part. You may receive additional 1095-B forms from more than one provider if you changed coverage in the past year.

For additional information about the 1095-B form you received, please click on the following link.

If you receive a letter from the IRS, please click on this link for additional information.

Of special interest to persons with disabilities:

If you think you are disabled, and if you meet the criteria for disability included in the Social Security Act, you may be eligible for Medicaid even if your income is otherwise too high.

If you believe you are disabled, you should furnish the local department of social services with medical evidence about your impairment(s).

It may be necessary for you to have further examinations and/or tests for the disability to be determined.

The cost of such examinations, consultations, and tests requested by the disability review team, if not otherwise covered, will be paid by the local social services agency.

NOTE: Persons who are denied for reasons of failure to meet the disability criteria are entitled to appeal the disability decision that led to the denial of their application. See the section of this page entitled 'What are my rights?'. Any person dissatisfied with the Fair Hearing decision of the New York State Office of Temporary and Disability Assistance may also appeal to the court system.

Medicaid Copay 2020

The following questions are only for people who are 65 years of age or older, certified blind, certified disabled, or in need of care in a nursing home. These individuals have a resource test.

Resource Test Information

What are resources?

Resources are cash or those assets, which can be readily converted to cash, such as bank accounts, life insurance policies, stocks, bonds, mutual fund shares and promissory notes. Resources also include property not readily converted to cash (i.e., real property)

Can I still keep part of my income if I am in a Residential Health Care Facility
or in an intermediate care facility for the developmentally disabled?

Yes. Under Medicaid you are allowed to keep a small amount for your personal needs. You can also keep some of your income for your family if they are dependent on you. A spouse who remains in the community may also keep resources and income above the levels shown.

What is a 'lookback' period?

When applying for Medicaid for nursing facility services (Nursing Home), the local department of social services will look at financial transactions to determine whether any assets have been transferred or given away for less than fair market value during a certain time period prior to your application in order to determine if a transfer of assets penalty period needs to be applied. This is known as the 'lookback' period. Currently the 'lookback' period is 60 months (5 yrs) prior to the month you are applying for coverage of nursing home care.

A penalty period may be imposed for the transfer of non-exempt assets for less than fair market value. The penalty period results in a period of ineligibility for Medicaid coverage of nursing facility services.

A penalty period is not applied for the transfer of your home to the following individuals:

• Spouse
• Child under the age of 21
• Sibling who has an equity interest in the home and has resided in the home for at least one year immediately prior to you entering the Nursing Home.
• Adult child who resided in the home for at least two years, immediately prior to you entering the Nursing Home and who provided care to you which permitted you to reside at home rather than in a medical facility.

For more information regarding the transfer of assets and penalty periods, please contact your local department of social services.

What is a Life Estate? Will it make me ineligible?

A life estate is limited interest in real property. A life estate holder does not have full title to the property, but has the use of the property for his or her lifetime, or for a specified period. The life estate is not considered a countable resource, and no lien may be placed on it.

If you or your spouse sell the life estate interest for less than fair market value, it can be considered a transfer of assets and may be subject to the penalty period.

Am I allowed to have a pre-paid burial fund?

You may establish an irrevocable pre-need funeral agreement with a funeral firm, funeral director, undertaker or any other person, firm or corporation which can create such an agreement for your funeral and burial expenses. Pre-need burial agreements purchased for certain members of your family on or after January 1, 2011 must also be irrevocable. The pre-need funeral agreement is used towards burial and funeral expenses and is not counted as a resource when determining Medicaid eligibility.

Waiving Copays For Medicaid Patients

If you (your spouse) do not have an irrevocable pre-need funeral agreement or if the irrevocable pre-need agreement has less than $1500 designated for non-burial space items, you may be allowed to have money set aside in a burial fund. The limit for single individuals is $1500 or $3000 for a couple. Please note, these funds, must be kept separate from any non- burial fund related resources.