New york medicaid program information

When a person has both Medicare and Medicaid, Medicare pays first and Medicaid pays second. 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. 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. If you send an e-mail to medicaid health. If you would like to authorize or change a representative at renewal or anytime in between renewals, you may fill out DOH and submit this with your renewal.

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.

You cannot get this home care from Medicaid unless you are found eligible for Medicaid. 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.

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

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

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.

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

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. See the pages titled "Terms, Rights and Responsibilities. 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. Box , Albany, New York Online: www. 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:. 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. 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.

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.

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. Only certified blind individuals, certified disabled individuals, and individuals over 65 have a resource test. For some pregnant women, services may be limited to perinatal care if their incomes are too high to qualify for full Medicaid coverage.

For example, Medicaid requires that all children be screened with a blood lead test at one and two years of age. Child Health Plus and Family Health Plus provide services to eligible children and adults, respectively, through managed care plans. For more information about Medicaid, visit the Medicaid website: www. Navigation menu. Medicaid Program Goal To increase access to health care coverage for low income individuals, families and children. Description Medicaid offers a full range of health services for eligible persons including: All regular medical checkups and needed follow-up care.

A claim submitted to Medicaid should never be higher than the B ceiling price. Claims that are denied with this reason code may be resubmitted with the correct ingredient cost. Please note: Any APGs fee schedule drug will still require a provider to code the number of units and the acquisition cost for the claim line to be paid. As communicated in the December issue of the Medicaid Update cited and linked in the beginning of this article, B claim level identifiers are required on all B purchased drug claims for Medicaid members.

Pharmacies should not submit claim level identifiers on nonB eligible items, such as test strips. Only B purchased drugs should be tagged when claim eligible with the B claim level identifiers. Tagging test strips, supplies, or any other nonB eligible item as a B drug causes a false claim which may be recovered during an audit.

Federal regulations require that all available resources be used before Medicaid considers payment. If there is a responsible third party who should be paying for the Medicaid member's health benefits as primary payor, that responsible third party must pay first.

As previously communicated in the October issue of the Medicaid Update , in the article titled Notification to Providers of Requirement to Attach Explanation of Benefits from Third-Party Payors to Medicaid Claims , failure to obtain prior authorization does not overcome the responsibility of the primary payor. Through coordination of benefits, Medicaid will pay the patient responsibility for correctly submitted Medicaid coverable claims or will pay up to the Medicaid allowed amounts for drugs in classes specifically excluded from being covered under the third-party liability TPL Plan,including Medicare.

A pharmacy provider who receives a zero-fill response must ensure that the claim was adjudicated within each TPL Plan claim process requirement. Additionally, a pharmacy not contracted with member TPL Plans may need to attempt overrides with plans, or enroll with the plans, or advise the members and prescribers of the need to change dispensing to network pharmacies. Prescribers are responsible for prescribing, per plan formulary, and to pursue any claim issues such as, but not limited to, the following:.

Pharmacies are responsible for submitting claims to other coverage before submitting claims to Medicaid. Pharmacies that have difficulty billing primary coverage should advise prescribers and members of potential delays as well as options for resolution.

If claim issues are resolved, the pharmacies may then resubmit the claims to Medicaid after the claims are properly adjudicated with the TPL Plans. Submitting TPL-covered claims that incorrectly bypass the TPL Plan responsibility of payment is considered inaccurate billing and may be subject to audit recoveries.

Reminder: Providers must maintain evidence and documentation, which are subject to audit, for a minimum of six years following the date of Medicaid payment. This evidence should include, but not be limited to, denials of claims by responsible TPL Plans, other applicable TPL Plan responses, and payment information.

This new edit will be an expansion of previously issued guidance:. Please note: Values "06" , "14" , "17" and "22" through "35" will have a prorated dispensing fee applied. Pharmacists may use SCC "10" and "21" for scenarios where drugs are dispensed in their original container, as indicated in the Food and Drug Administration FDA prescribing information, or those that are customarily dispensed in their original packaging to assist patients with compliance.

Reminder: Medicine cabinet drugs and emergency kit replenishment is included in the LTC rate and may not be separately billed to Medicaid. Mary T. Bassett, M. Brett R. Navigation menu. Definitions: "ILS" is used to define an alternative physical and behavioral health service or setting, not included in the State Plan, that is a "medically appropriate and cost effective" substitute for a covered service or setting.

Non-Drug Items As communicated in the December issue of the Medicaid Update cited and linked in the beginning of this article, B claim level identifiers are required on all B purchased drug claims for Medicaid members.