Guide to Medicaid in New York

New York state has one of the largest populations covered by Medicaid programs, with nearly 9 million people receiving benefits as of 2023. The healthcare program, designed for lower-income and certain disabled New Yorkers, covers people of all ages, but eligibility requirements vary.

Whether you are looking for help with medical care after a job loss or you need additional coverage to help with the birth of a child, the New York Medicaid program may be able to help. Here is what you should know about this coverage option.

Eligibility for Medicaid in New York

You may be able to get healthcare coverage through New York’s Medicaid program if you meet the eligibility criteria. Your situation determines if you will apply through the New York State of Health or your Local Department of Social Services (LDSS). It’s important to note that eligibility for Medicaid is determined by a holistic assessment of various factors, and age or family living arrangement alone may not be the sole basis for qualification. Additionally, you generally have the flexibility to apply through either method regardless of your circumstances.

Income requirements

New York Medicaid uses a household’s Modified Adjusted Gross Income (MAGI) in determining eligibility. The exact amount you can make and still qualify changes every year, as it is adjusted to account for inflation. Resources, such as bank accounts or cars, may be counted in the case of someone who is older than 65, blind, or disabled applying for coverage. Everyone who lives in the household will have their income and resources counted when applying.

Age requirements

Many age groups qualify for Medicaid if their MAGI is below the threshold. These include the following:

• Adults 19-64 years of age who are not eligible for Medicare
• Children 1-18 years of age
• Infants (younger than 1)
• Youth in foster care and former foster care youth

Children not eligible for Medicaid may be able to get coverage through Child Health Plus, an expanded health insurance program. Additional coverage may be available for those age 65 and older who are not caregivers.

Disability status

Some New York residents may qualify if they have a disability. The following groups may be covered under “non-MAGI” eligibility rules:

• Residents of group adult homes run by the LDSS and other communities
• Those who are aged, blind, or disabled and don’t qualify by other means

Citizenship or immigration status

New York Medicaid is available to New York residents who are citizens or legal immigrants of the United States. Documentation, including birth certificates or social security numbers, is usually required to prove eligibility.

New York Medicaid benefits

New York must follow the minimum federal requirements for covered services, but it also covers additional services, too.

Medical services covered

New York Medicaid covers medically necessary services, including doctor’s visits, specialist visits, family planning services, hospital services, transportation to medical appointments, X-rays, and diagnostics.

It also covers:

• Smoking cessation services and treatments
• Community-based long-term care
• Nursing home / institutional care
• Psychiatric care, including inpatient treatment

New York recently expanded its coverage with Medicaid changes for pregnant women to include or increase reimbursement rates for the following services:

• Doula coverage
• Midwifery services
• Remote patient monitoring
• Nutrition counseling
• Lactation counseling
• Expanded prenatal testing services

Children with Medicaid plans get well-child care visits and childhood immunizations covered, as well.

Prescription drug coverage

Under the New York State Medicaid Pharmacy program (NYRx), FDA-approved and medically necessary drugs are eligible for coverage. You will need a prescription for anything that’s not over-the-counter (OTC), and some controlled substances require additional authorization from your provider before they will be covered. It’s important to note that individuals with both Medicare and Medicaid will obtain their prescriptions via Medicare Part D, not through Medicaid.

Dental coverage

New York recently updated dental coverage to provide benefits for basic dental services under Medicaid. This includes checkups, cleanings, X-rays, and fillings without a referral from a primary care healthcare provider.

Vision coverage

Vision care, including eye exams and prescription eyeglasses, is covered by Medicaid in New York. Depending on your plan, you may get access to additional services.

Long-term care coverage

Medicaid-managed care plans may pay for medically necessary long-term care, including nursing homes with 24/7 medical care, therapy, and assistance with daily activities. The long-term care must be ordered by a healthcare provider and approved by your Medicaid-managed care plan. Income and assets may be a factor in determining how much a patient will put toward the costs.

Mental health and substance abuse coverage

New York Medicaid covers the following services:

• Treatment in psychiatric hospitals
• Services provided in mental health facilities
• Services from the Office of Mental Health (OMH)
• Medication-assisted treatment facility services (MAT)

Additional mental health or drug abuse treatment services may be covered. Contact the facility to see if they accept Medicaid before making an appointment.

Medicaid Excess Income in New York

Even if you make more money than the state’s guidelines, you may still be eligible for the Medical Excess Income (“Spenddown” or “Surplus Income”) Program. This helps you with medical bills after you pay a portion of the amount, with the full amount you pay dependent on your income. The program covers you for one month or three months at a time, depending on the help needed. It may also pay medical bills from the three months prior to getting coverage.

You must be under age 21, age 65 or older, certified blind or certified disabled, pregnant, or a parent of a child under age 21 to qualify for the Excess Income program. If you do qualify you will apply through the LDSS. 

Medicaid Managed Care in New York

New York Medicaid contracts with private health insurers in the state to deliver insurance coverage services, but the companies and plan types vary by county. Use the plan finder tool to see what options exist where you live.

How to apply for New York Medicaid

Applications for Medicaid can happen at any time, and you don’t have to wait for ACA open enrollment to get started.

You can also call and speak to the Marketplace Customer Service Center at (855)355-5777 or the Medicaid Helpline at (800)541-2831.

Required documents for application

The exact paperwork you need depends on the program you are applying for. MAGI-based programs will ask for the following:

• Household income for the upcoming year
• Citizenship or immigration status and documentation
• Social Security Number

Non-MAGI programs will ask for the following:

• Social Security Number for U.S.-born citizens or a Naturalization Certificate for naturalized citizens
• Proof of immigration or citizenship status
• Proof of age 
• Four weeks of recent paychecks or income from Social Security, Veteran’s Benefits, Child Support, or Unemployment Benefits
• Bank statements and other proof of assets (if applying for nursing home care and over 65 years of age or certified blind or disabled)
• Proof of residency, such as a rent receipt or mortgage statement
• Proof of any current insurance coverage (Medicare or other health insurance policy)

You may also be asked to show proof that you applied for Medicare if you are 65 years or older.

The state of New York may ask for clarifying information in addition to these items at any time during your application process.

Online application process

The best way to apply for Medicaid is through an online application. This will get you the quickest response and can help you track your submission.

Paper application process

Those applying for non-MAGI coverage, such as those blind, disabled, or over age 65, send in a paper application. Note that you can still call and ask for help with the application, and blind applicants may be able to get assistance with a large-print application. You can also bring the paper to a local office.

Cost of New York Medicaid

If you qualify for Medicaid coverage, there is no monthly premium to pay. You may have to pay a small copay at the time of service, depending on your financial situation. Those who don’t qualify for standard New York Medicaid but get coverage through the Spenddown program will have to pay until they meet their excess income amount and then will have help paying the rest of their bills.

Medicaid Information | NY State of Health

Additional New York Medicaid resources

The best way to learn about New York Medicaid is by visiting the following sites:

• New York State of Health Medicaid Information

• New York Health Insurance Marketplace

• Important Medicaid Phone Numbers

New York Medicaid FAQ

How do you find a doctor who accepts Medicaid?

The best way to find out if your current healthcare provider or facility accepts Medicaid is to ask before you receive services since their insurance agreements may change. You can also use the New York provider website to search by your type of Medicaid plan and the facility or provider you like best. It will provide a list of options for new doctors or hospitals if you don’t already have one.

How to renew Medicaid coverage?

As long as you don’t have a lapse in coverage, you don’t have to reapply every year for Medicaid. You will be given a chance to update your information every 12 months as part of a renewal process. If you haven’t updated your contact information, such as address and phone number, since you applied, you will want to do that when you renew. If you remain eligible, you will continue to be covered.

How to report Medicaid fraud?

If you believe your healthcare provider, a service provider, or someone you know is committing fraud or using their Medicaid card in a way they shouldn’t, you can contact the Medicaid Fraud Hotline at 1–877–87 FRAUD.