Learn About Coverage For Medicaid in New York

Learn How To Apply For Medicaid With Our Guide

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UPDATE: In 2020, most of the requirements for Medicaid remain the same.

New York Medicaid coverage enables low-income families and individuals to get affordable and quality health care. Some Medicaid services are offered completely free-of-charge, while others require varying co-payments.

If you want to learn more about NY Medicaid costs and coverage, continue below, and you will find the answers to the following questions:

How Much Does Medicaid Cost in New York?

Medicaid cost estimates in New York vary depending on the patient, as well as the services sought. Most Medicaid services are offered for free, but a few have copayment requirements. Still, the Medicaid coverage copayments are small, and Medicaid enrollees are entitled to health services, even when they cannot pay.

New York Medicaid coverage excludes enrollees in various categories from paying copayments. These enrollees include members who are age 21 years or younger, pregnant women, enrollees in Managed Long-Term Care plans, recipients enrolled in the Department of Health (DOH) Home and Community Based Services (HCBS) Waiver Program for Persons with Traumatic Brain Injuries (HCBS/TBI) and nursing home residents.

NY Medicaid cost estimates do not apply to some healthcare services. Examples include:

  • Medical services provided in a dental or a private doctor office.
  • Urgent services received in an emergency room.
  • Pregnancy-related services (e.g. hospital stays for childbirth, an emergency condition or prenatal care).
  • Family planning products (contraceptive creams, diaphragms, condoms, and birth control pills).
  • X-rays for emergencies.
  • Drugs to treat mental illnesses.
  • Tuberculosis medications.

To estimate Medicaid costs in NY, confirm with your physician whether the services you need require copayments first. Download our informative guide to get more details on Medicaid coverage and costs today.

What Services are Covered by Medicaid in New York?

NY Medicaid coverage generally pays for the majority of medical services, as well as the supplies and medications needed. However, when it comes to what is covered by Medicaid, enrollees may not be eligible for some of the healthcare services or items due to their living arrangements, transfer of resource requirements, family situations, financial circumstances or ages. Moreover, some Medicaid services require copayments.

Your New York Medicaid coverage may pay for the following services:

  • Prenatal care, family planning services, and clinic services
  • Emergency ambulance transportation to the hospital
  • Car mileage and public transportation to medical appointments
  • Appliances, medical equipment, supplies, and medicines
  • Early periodic screenings, diagnosis, and treatment for enrollees that are 21 years old or younger
  • Facilities for the developmentally disabled, the mentally disabled, mental health facilities and treatment in psychiatric hospitals (for members below 21 or above 65)
  • Personal care and care through home health agencies
  • X-ray and laboratory services and care in a nursing home
  • Hospital outpatient and inpatient services
  • Preventive health, treatment, and dental care and smoking cessation agents

When you estimate Medicaid costs, note that there are certain circumstances regarding managed care plans. The only instance in which you are responsible for payment is for pharmacy services, where you will have to make a small co-pay in order to receive the medication you need.

When your NY Medicaid services application has been approved, you will be given a Benefit Identification Card. How much does NY Medicaid cost in terms of services and medications? Your New York Medicaid ID card is a determining factor when it comes to both of these instances. By downloading our in-depth guide, you will learn more about the coverage options for Medicaid and more details.

While reviewing what services are covered by Medicaid in NY, note that some services and treatments require approval from your primary care provider (PCP) in order to be covered. This is known as prior authorization. Some of the services requiring pre-authorization include outpatient therapeutic and diagnostics procedures, morbid obesity treatments, elective inpatient admission, and various ambulatory surgery procedures.

Find out what is covered by Medicaid from your PCP before selecting any procedure. The PCP can request for authorization of services that require prior authorization with your health plan. NY Medicaid coverage will not pay for a service offered without approval.

What Does Medicaid Not Cover?

Regarding what is not covered by Medicaid, you may be financially responsible for any services unapproved by your PCP. The same also applies if you agree to a “self-pay” or “private-pay” before the service is offered. Generally, NY Medicaid coverage excludes services offered by providers that are not part of your Medicaid plan, unauthorized or unapproved services, and non-covered services.

What does Medicaid not cover in NY, specifically? You may have to pay the bill through a third party insurance company or from your pocket if you receive the following health services through New York Medicaid:

  • Medicaid services requiring approval or a referral in advance, of which you did not request prior
  • Services from an out-of-network medical provider, unless the provider has been referred by your PCP or your health plan
  • Infertility services
  • Personal and comfort items, such as TV, while in the hospital
  • Podiatry services for members over 21, unless diabetic
  • Elective cosmetic surgery
  • Services that are considered investigational or experimental
  • Weight loss programs, unless when approved by your PCP
  • New Age or Christian Science treatments

If you require any of the above services or procedures, speak to your PCP prior to scheduling. When it comes to paying for out-of-pocket New York Medicaid services, you may be able to request a payment plan to alleviate the possibility of a large, one-time medical bill that may seem unaffordable up front.

What Types of Medicaid Insurance are Offered in New York?

Medicaid types of insurance vary in New York. The types of insurance you can put in for during the application process will depend on the Managed Care Plan you choose. If you do not select a health plan, one will be assigned on your behalf.

Different types of Medicaid insurance in New York are offered by the following: Affinity Health Plan, Fidelis Care New York, HIP (Emblem Health), Health Plus Amerigroup, Healthfirst PHSP, Inc., MetroPlus Health Plan, United Healthcare Community Plan and WellCare of New York.

The Medicaid coverage New York offers for HIV Special Needs Plans includes MetroPlus Health Plan Partnership in Care, VNS CHOICE SNP or Amida Care. NY Medicaid coverage health plans have a network of pharmacies, hospitals, clinics, and doctors that provide health care. Not that you will have to choose one of the doctors from your health plan network to be your Primary Care Provider (PCP).