Medicaid

Medicaid is a program for people who cannot afford to pay for medical care.
 

You may be covered by Medicaid if:

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

 

Please read the categories below to determine where you apply for Medicaid.

If you are:

  • Adult (not pregnant) and aged 19-64, not eligible for Medicare;
  • Pregnant Women and Infants;
  • Children ages 1 - 18
  • Parents and Caretaker Relative
  • Childless Adults who are: not pregnant, age 19-64, not on Medicare, and could be certified disabled but not on Medicare
  • Family Planning Benefit Program
  • Children in Foster Care (Chafee)

You may qualify under Medicaid Eligibility under the Affordable Care Act (MAGI) and should apply through the NY State of Health Marketplace.  Applications may be completed online, in person with a navigator or certified application counselor, by mail and by phone (855) 355-5777.

If you are:

  • 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);
  • COBRA
  • 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 Local Department of Social Services (LDSS).

You should apply through Clinton County Department of Social Services as Non-MAGI.  Applications may be completed and mailed, or hand-delivered to Clinton County Department of Social Services, 13 Durkee Street, Plattsburgh, NY 12901 – or faxed to 518-561-8101. 

The following paper application and Supplement A 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.

Application 4220 & Supplement A – 5178A ***need form***

The applications listed above, along with other applications and forms that may be needed to be completed, depending on the Medicaid category you are in can be found on the New York State Department of Health Alternative Format Forms page.
 

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.

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.

 

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.

2018 Income & Resource Levels*
Family Size Net Income for Individuals who are Blind, Disabled or Age 65+ Medicaid Income Level for Single People, Couples without Children  Resource Level (Individuals who are Blind, Disabled or Age 65+ ONLY)
Annual Monthly Annual  Monthly 
1 $10,100 $842   $16,754  $1,397 $15,150
2 $14,800 $1,233 $22,715 $1,893 $22,200
3 $17,020 $1,418 $28,677 $2,390 $25,013
4 $19,240 $1,603 $34,638 $2,887 $28,275
5 $21,460 $1,788 $40,600  $3,384 $31,539
6 $23,680 $1,973 $46,562 $3,881 $34,800
7 $25,900 $2,158 $52,523 $4,377 $38,064
8 $28,120 $2,343 $58,485 $4,874 $41,325
9 $30,340 $2,528 $64,446 $5,371 $44,588
10 $32,560 $2,713 $70,408 $5,868 $47,850
For each additional person, add:  $2,220 $185  $5,962 $497 $3,263

*Effective January 1, 2018

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.

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.

Individuals who are certified blind, certified disabled, or age 65 or older who have more resources may also be eligible.

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

  • Family Planning Benefit Program

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, 2018*
Number in Family 154% FPL** 223% FPL**
1 $1,558 $2,257
2 $2,113 $3,059
3 $2,667 $3,862
4 $3,222 $4,665
5 $3,776 $5,468
6 $4,330 $6,271
7 $4,885 $7,073
8 $5,439 $7,876
For each additional person, add: $555 $803

* Income Levels are subject to yearly adjustments.

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.

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.

 

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.
 

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.

 

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).

  • 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.

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.
 

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.
 

Most people in Clinton County do have to join a Managed Care plan. There are some individuals who don´t have to join. Please check with Clinton County Department of Social Services to see if you are required to  join a plan..
 

If your Medicaid is with your LDSS, to order a new Medicaid Benefit Identification Card, please call 518-565-3330 or at 13 Durkee Street Plattsburgh, NY 12901.

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 855-355-5777.

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. (IF YOU ARE TEMPORARILY AWAY, WE NEED A FORWARDING ADDRESS TO SEND MAIL TO)

If your Medicaid is at 13 DURKEE STREET IN PLATTSBURGH, NY, 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. You can report your address at 518-565-3330.

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.

 

 

Additional information for those 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.