Medicaid Costs and Coverage in New York

For those residents wondering, “How much is Medicaid in New York?” answers will depend on the type of coverage and the participant’s medical history. Medicaid cost estimates vary depending on the plan petitioners qualify for and health care services needed. All Medicaid cost options are designed to make quality health care attainable for low-income families and individuals with qualifying conditions. Many Medicaid services in New York are offered for free or for small copayments. Different types of Medicaid insurance are made available to specialized groups of people in order to get everyone the best coverage at the lowest price. As a result, Medicaid coverage, including which services are covered by the program, can differ between groups.

How much does Medicaid cost in New York?

It is important to know how much is Medicaid, as participants will be financially responsible for copayments and non-covered services. Obtaining affordable Medicaid coverage can seem like a lengthy process, but the Medicaid program in New York is highly regarded as one of the most progressive in the country and enrollees will be entitled to medical services even when they cannot pay. Medicaid cost estimates for the following subgroups exclude copayments altogether:

  • Pregnant women
  • Recipients of Managed Long-Term Care Plans
  • Nursing home residents
  • Participants in the Department of Health Home and Community Based Services Waiver for Persons with Traumatic Brain Injuries
  • Any recipient younger than 21 years of age

All residents who meet Medicaid eligibility in New York will have less expensive health care costs, but Medicaid coverage is significantly lower for these copayment-free subgroups. Medicaid insurance for some of these participants will also be more comprehensive. For example, what services are covered by Medicaid for adults are more limited than those for young children.

Program coverage extends beyond typical Medicaid cost estimates with regard to several kinds of basic and emergency medical care. Examples of health services that are not factored in to traditional Medicaid cost estimates and thus do not have copayments are are any kind of home health services, personal care services, private practice physician services (such as X-rays and laboratory work) or long-term care services. Medicaid costs in these specialized circumstances become a more attainable figure. Common health services that are included in Medicaid coverage that do carry a copayment fee are pharmacy prescription drugs, inpatient hospital stays, basic medical supplies (such as bandages, syringes, incontinence pads or gloves), clinic visits, laboratory tests from independent clinical laboratories or hospital-based laboratories and non-prescription over-the-counter drugs. Download our comprehensive Medicaid guide for details about which health care services are considered mandatory for all enrollees.

What services are covered by Medicaid in New York?

Services covered by Medicaid in New York are wide-ranging and varied. Medicaid coverage basically encompasses nearly every kind of medical situation that is medically necessary as well as the prescription drugs and health supplies. Medicaid covers hospital inpatient and outpatient services, laboratory services, hospice and nursing home care. Medicaid cost estimates include car mileage or public transportation to and from medical appointments, smoking cessation help, necessary medical equipment (such as wheel chairs, diabetic needles or orthopedic shoes), prenatal care, dental care and personal care services through home health agencies.

Some Medicaid coverage is specific to the age of the Medicaid enrollee. Medicaid will cover early periodic screenings and diagnostic testing for recipients younger than 21 years of age as well as mental health and developmental disability care for recipients younger than 21 or older than 65 years of age. Other services covered by Medicaid in New York specify subgroups, such as services for American Indians who have ever received a health service from the Indian Health Service. Enrollees will find out which select services they may receive after completing the Medicaid application process in New York.

One important thing to remember when it comes to what services are covered by Medicaid is that every recipient may not be automatically able to partake of every service in the same way or at the same rate, as some of that eligibility is determined by family circumstances, financial situations, age, living arrangements or even transfer of resources requirements. Medicaid cost estimates in New York include some Medicare premiums and associated premium costs of other health insurance policies. As a New York Medicaid recipient, enrollees will receive a Benefit Identification Card, which will essentially serve as a passport to health services through Medicaid. In order to make the most of services covered by Medicaid, participants will be required to show their Benefit Identification Card prior to receiving medical services at any facility. The Medicaid information presented on this card informs the health care provider of which services the cardholder qualifies for.

Medicaid coverage in New York for some specialized services requires prior authorization from your Primary Care Provider (PCP). Examples of services that require prior authorization are treatment for morbid obesity, certain ambulatory surgery procedures, elective inpatient admission and some outpatient therapeutic or diagnostic treatments. It is important for enrollees to know what does Medicaid not cover, as they will not be compensated for these treatments and supplies.

What does Medicaid not cover in New York?

In general, Medicaid coverage does not include any services not approved through your Primary Care Physician (PCP). Medicaid coverage in New York typically does not extend to infertility treatments, weight-loss programs, elective cosmetic surgery, podiatry services for recipients older than 21 years of age (unless diabetic), services labeled as “New Age” or “Christian Science” or medically experimental services. Services covered by Medicaid normally will not be covered if rendered by an out-of-network medical practitioner.

Participants may have agreed to out-of-pocket expense (self-pay) before the service was provided and will still be personally financially responsible for those procedures. In most cases, whatever expenses do not fall under the umbrella of your New York Medicaid coverage can still be broken down into small, incremental payments so that enrollees do not have to pay large lump sums up front. In efforts to shrink costs of what Medicaid does not cover, participants should talk openly about specific medical needs with their PCP prior to seeking any out-of-network or specialty services. Providers can send medical information about Medicaid participants to the program in an effort to obtain coverage. Medicaid coverage may be granted with PCP approval for prior authorization.

What types of Medicaid insurance in New York are available?

New York Medicaid coverage will depend largely on the Managed Care Plan that participants choose once deemed eligible for benefits. The highly personalized types of Medicaid insurance available in New York cater to the specific medical and financial needs of different beneficiaries. If enrollees do not immediately select a Managed Care Plan, one will be designated to them. The following companies provide a few of the varied types of Medicaid insurance in New York:

  • United Healthcare Community Plan
  • MetroPlus Health Plan
  • Affinity Health Plan
  • Fidelis Plan New York
  • Wellcare of New York

Participants also have the option of attaining Medicaid coverage in New York from HIP (Emblem Health), Health Plus Amerigroup or Healthfirst PHSP, Incorporated. For more details on Medicaid cost estimates, download our national Medicaid guide today.