Keith Mack
New York State's Medicaid laws are subject to frequent changes, with periodic updates to the Medicaid Reference Guide to reflect the pace of change. The state's Medicaid program provides comprehensive health coverage to over 7.5 million New Yorkers, and understanding eligibility is crucial for applicants. Recent changes include increased income limits, expanded coverage for seniors, the disabled, and the blind, and adjustments to the 'look-back' period for community-based Medicaid, impacting asset transfers. These changes aim to bring Medicaid access to more residents, but careful planning is necessary to navigate eligibility requirements and preserve estates.
| Characteristics | Values |
|---|---|
| Income limits | Increased in 2023 |
| Resource limits | Increased in 2023 |
| Medicare Savings Program | Restructured in 2023 |
| Medicaid Buy-In Program for Working People with Disabilities | Increased resource limits in 2023 |
| Community-Based Medicaid | 30-month look-back period implemented in 2022 |
| Home and Community-Based Long-Term Care Services | 30-month look-back period to be implemented in 2025 |
| State Medicaid Health Equity Regional Organization Initiative | Launched in 2025 |
| Health Insurance Renewal | Renewal process available through New York Medicaid |
| Medicaid Telehealth Services | Available during the Coronavirus emergency |
| Medicaid Coverage | Available for more than 7.5 million New Yorkers as of December 2023 |
| Medicaid Eligibility | Financial eligibility criteria change annually |
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What You'll Learn
Income limits for eligibility
In 2025, a single Nursing Home Medicaid applicant must meet the following criteria:
- Income under $1,800 per month
- Assets under $32,396
- Require a Nursing Home Level of Care
In 2025, the medically needy income level is $1,800 per month for a single applicant and $2,433 per month for a couple. The "spend down" amount is the difference between one's monthly income and the medically needy income level. Once the "spend down" has been met, one will be Medicaid-eligible for the remainder of the month.
For Regular Medicaid / Disabled, Aged 65+ or Blind (DAB), the income of both spouses is calculated towards the applicant's income eligibility. There is no Community Spouse Monthly Income Allowance for a non-applicant spouse. Countable assets (often called resources) are calculated towards Medicaid's asset limit. This includes cash, stocks, bonds, investments, vacation homes, and bank accounts. There are also exempt (non-countable) assets. Exemptions generally include one's primary home, personal belongings, household items, a vehicle, burial funds up to $1,500, or a life insurance policy with a cash value of up to $1,500, and non-refundable prepaid funeral agreements. In New York, IRAs and 401Ks in payout status are exempt.
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Reimbursement of care costs
New York's Medicaid program provides comprehensive health coverage to more than 7.5 million New Yorkers. Medicaid pays for a wide range of services, depending on the individual's age, financial circumstances, family situation, or living arrangements. The program is administered by the state under federally set parameters. New York's Department of Health (DOH) and local Departments of Social Services (DSS) administer the program.
Medicaid's reimbursement of care costs is subject to eligibility criteria. For instance, Medicaid offers reimbursement of third-party health insurance copayments related to care and services during the three-month retroactive eligibility period before the date of the Medicaid application. If the amount of the co-pay exceeds the Medicaid fee or rate for the service, reimbursement is made up to the Medicaid fee or rate; otherwise, full reimbursement of the co-pay is made. Co-pays related to third-party health insurance paid for care and services on or after the date of application and until the recipient receives their Common Benefit Identification Card (CBIC) are also eligible for reimbursement but must be obtained from an enrolled provider.
Additionally, Medicaid may reimburse the cost of third-party health insurance premiums during the retroactive eligibility period if it is determined to be cost-effective. By paying the premium, Medicaid may avoid claims that would otherwise be covered by the program. However, it is generally not cost-effective to reimburse an individual for third-party health insurance premiums during the retroactive eligibility period.
Medicaid also offers reimbursement for specific services, such as doctor's visits and prescriptions, which are considered medical expenses incurred by the individual.
The reimbursement methodology for outpatient mental health services is aligned with New York State's overall healthcare policy goals. The current reimbursement structure includes a Medicaid base rate and supplementary payments. The base rate is determined either regionally, with providers in the New York City metropolitan area receiving a higher rate, or on a cost-related, provider-specific basis, including an operating component capped at $67.50 and an uncapped capital component.
However, a report by PCG concluded that the current system of financing and reimbursement for outpatient mental health services requires a complete overhaul. Changes should be guided by the needs of Medicaid enrollees and research on effective care models. Restructuring should aim for a more equitable system that aligns with the state's mental health and healthcare goals. The report found substantial variance in reimbursements, costs, and deficits among providers, with a net deficit of $50.7 million for the agencies and programs included in the study.
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Benefits for elderly people
New York's Medicaid program provides comprehensive health coverage to more than 7.5 million New Yorkers. The program is administered by the state under federally set parameters and offers a range of benefits for elderly people.
Firstly, Medicaid in New York is sometimes called Medicaid Managed Care, and is available to those who are disabled, aged 65 or above, or blind. This is also called NON-MAGI (Modified Adjusted Gross Income) Medicaid. The American Council on Aging offers a free and quick Medicaid Eligibility Test for seniors.
Secondly, there are various programs under New York Medicaid that offer benefits for the elderly. These include:
- New York Managed Long-Term Care (MLTC) Program Waiver: This program is intended for seniors who require a Nursing Facility Level of Care but prefer to live at home or in an assisted living facility. Long-term care supports are provided to promote independence and may include personal care assistance, adult day care, meal delivery, and home modifications.
- New York Community First Choice Option (CFCO): This option allows elderly individuals to receive long-term home and community-based services under the state Medicaid plan. Benefits might include assistance with daily living activities, home health aides, and assistive technology.
- New York Assisted Living Program (ALP): This program pays for services in adult care facilities for seniors who require a Nursing Home Level of Care. Services might include skilled nursing, personal care, personal emergency response systems, and housecleaning.
- Nursing Home Transition and Diversion (NHTD) Waiver: This program helps nursing home residents transition back to community living by providing assistance with security deposits, utility set-up fees, and essential home furnishings.
- State Plan Personal Care Services (PCS) Program: This program is for New Yorkers who are elderly or disabled and require assistance with daily living activities. Housekeeping and personal care services are available and may include help with bathing, dressing, meal preparation, laundry, shopping for groceries, and light housecleaning.
- Program of All-Inclusive Care for the Elderly (PACE): This program combines the benefits of Medicaid, including long-term care, and Medicare into a single program. Additional benefits, such as dental and eye care, may be available.
- Money Follows the Person (MFP) or Open Doors in New York: This federal program assists institutionalized persons who are eligible for Medicaid to transition back home or into the community.
It is important to note that financial eligibility criteria for these programs change annually and vary based on marital status. Additionally, New York offers alternative pathways towards eligibility, making the process more accessible for seniors.
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Eligibility for disabled people
Eligibility for Medicaid in New York depends on age, income, financial circumstances, family situation, or living arrangements. Medicaid is a health care program for low-income persons of all ages, including disabled individuals.
Disabled persons over 65 years old who are not a parent or caretaker relative of minor children, anyone who has Medicare, and persons seeking to qualify for Medicaid based on a disability must apply for coverage through New York City's Human Resources Administration (HRA). There is no online application option for New Yorkers 65+ years old.
The State Plan Personal Care Services (PCS) Program is available for disabled New Yorkers who require assistance with daily living activities. This includes services like housekeeping, bathing, dressing, meal preparation, laundry, shopping for groceries, and light house cleaning.
Additionally, the Program of All-Inclusive Care for the Elderly (PACE) combines the benefits of Medicaid and Medicare into a single program, offering long-term care and additional benefits such as dental and eye care.
The Money Follows the Person (MFP) program, also called Open Doors in New York, assists institutionalized Medicaid-eligible individuals in transitioning back to living in the community or at home.
The income eligibility criteria for Medicaid change annually and vary based on marital status. In 2025, a single nursing home Medicaid applicant must have an income under $1,800 per month and assets under $32,396. While one's home is generally exempt from Medicaid's asset limit, it is subject to the Medicaid Estate Recovery Program, which seeks reimbursement for care costs through the estate of the deceased.
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$54.95 $210
Medicaid Excess Income Program
New York's Medicaid program provides comprehensive health coverage to more than 7.5 million New Yorkers. Medicaid pays for a wide range of services, depending on one's age, financial circumstances, family situation, or living arrangements. These services are provided through a large network of healthcare providers that can be directly accessed using one's Medicaid card or through a managed care plan if enrolled in managed care.
The Medicaid Excess Income Program, sometimes called the "Spenddown program" or the "Surplus Income program", is designed for individuals whose monthly income exceeds the Medicaid level. This program allows individuals to receive help with their medical bills even if they are not eligible for Medicaid coverage. The excess income is used to meet the "spenddown" requirement, which is the amount of excess income that must be spent on medical bills before becoming eligible for Medicaid coverage. The "spenddown" amount is determined by taking into account one's income and certain allowable deductions.
To participate in the Medicaid Excess Income Program, individuals must meet certain eligibility criteria and guidelines. Firstly, they must have income that exceeds the regular Medicaid income limits in New York State. Secondly, they must provide documentation of their medical expenses, including bills, receipts, and other relevant documentation. These medical expenses must be related to their health condition and meet the program's guidelines. It is important to note that the Medicaid Excess Income Program can be complex, and eligibility rules and requirements may vary based on individual circumstances.
The process of enrolling in the Medicaid Excess Income Program typically involves contacting or visiting one's local department of social services to express interest in the program. A Medicaid caseworker will then determine the monthly excess income amount by calculating the difference between the monthly Medicaid income limit and the individual's countable income, taking into account any applicable deductions. Once enrolled, individuals can submit medical bills to count toward their excess income, even if they have not yet paid those bills. This can be done by fax or in person at a DSS/Medicaid office, depending on the district and the individual's capabilities.
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Frequently asked questions
It is a joint federal and state program that allows people to receive thousands of dollars worth of healthcare benefits, as long as they can prove financial eligibility.
Eligibility is based on age, financial circumstances, family situation, or living arrangements. For instance, individuals applying for Medicaid can earn up to $1677 per month ($20,121 per year), and couples can earn up to $2268 per month ($27,214 per year) without risking their benefits.
Pregnant individuals and children can apply at many clinics, hospitals, and provider offices. Seniors can apply in person at their Local Department of Social Services (LDSS) office, or they can call their local office and apply via phone.
The pace of change within the New York State Medicaid program makes periodic replacement of the Medicaid Reference Guide pages essential to maintain its validity as a current working document. Information contained in the Medicaid Reference Guide is revised and updated on a regular basis.
