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Medicaid 101

January 15, 2009


By Trilby de Jung
Senior Health Law Attorney
Empire Justice Center

I. Medicaid is a Patchwork of Programs

a. The federal Medicaid program. Medicaid was initially created under federal law as a joint, federal-state entitlement program.  Individuals have a legal right to payment for covered services that are medically necessary. Also, states have a legal right to federal contributions to state expenditures. See 42 U.S.C. § 1396 et seq., 42 C.F.R. § 430 et seq.

Federal payments to the states come with some conditions:

i. Federal law sets forth a minimum level of services, referred to as “mandatory services,” to be provided to specified “mandatory” populations of low-income persons.
ii. Federal law also requires sufficient amount, duration and scope of services, to be furnished with reasonable promptness, comparability to what others receive and statewideness.
iii. Medicaid is the payer of last resort and is payment in full.
iv. States are required to describe their Medicaid programs in formal state plans, which are submitted to the federal Center for Medicare and Medicaid Services (CMS) for approval.
v. Federal law also authorizes states to experiment with new and different ways of structuring health care services for the low-income by proposing waivers to CMS for approval.

b. New York’s Medicaid Program itself is actually a conglomeration of different public health programs governed by state statute, regulation and sub-regulatory administrative directives issued by the New York State Department of Health (NYSDOH) for the benefit of local counties, which are charged with determining eligibility.

New York’s major public health insurance programs include:

i. Regular Medicaid, (termed Medical Assistance by state statute). Regular Medicaid includes the Medically Needy program with spend down for caretaker adults and the elderly and disabled, as well as Medicaid without spend down for single adults and childless couples. Regular Medicaid is described in New York’s State Plan and codified at N.Y. Soc. Serv. L. §§ 122, 131, 363- 369-1; 18 N.Y.C.R.R. §
360, 505.
ii. Family Health Plus (FHPlus) is an extension of New York’s Medicaid Program that provides health coverage for adults who are over-income for regular Medicaid. FHPlus is described in New York’s 1115 waiver and codified at N.Y. Soc. Serv. L. §369-ee. Services are provided through managed care plans only and do not include long term care.
iii. Child Health Plus (CHPlus), is a sliding scale premium program for children who are over-income for regular Medicaid. is codified at N.Y. Pub. Health L. §2510 et seq. Eligibility is determined by health plans under contract with NYSDOH. Services are provided through managed care plans only and do not include long term care.
iv. Emergency Medicaid - Emergency Medicaid can cover treatment for emergency medical conditions for undocumented immigrants and non-citizen, nonimmigrants, as long as they satisfy all other eligibility requirements for Medicaid. Residency becomes an issue for those here on temporary visas. An emergency medical condition is narrowly defined as a condition that, after sudden onset, has acute and severe symptoms which if left untreated could place the applicant’s health in jeopardy.  See N.Y. Soc. Servs. L. § 122(1)(e); 00 OMM/ADM-9 and 04 OMM/ADM-7.
v. The Prenatal Care Assistance Program (PCAP) is a program for pregnant women and children up to age one in families with income up to 200% of the federal poverty level. PCAP
is codified at N.Y. Pub. Health L. § 2529 and N.Y. Soc. Serv. L. §365-a(6).
vi. The Family Planning Benefit Program (FPBP) was created as part of the 1115 waiver that also created the FHPlus program in New York. FPBP provides family planning services, including birth control and emergency contraception, to women of child-bearing age up to 200% of the federal poverty level. Other health services may be covered as well, when related to family planning decisions.  FPBP is codified at N.Y. Soc. Serv. L. § 366(1)(a)(11)
vii. The Medicaid Buy-In Program for Working People with Disabilities (MBI-WPD) – The MBI-WPD program provides full Medicaid coverage to people with disabilities who are working, at incomes levels significantly above the income level for Regular Medicaid. The MBI-WPD program is codified at N.Y. Soc. Serv. L. §366(1)(a)(12).  Implementation of the program remains problematic at the
county level, despite numerous administrative directives from the State Department of Health to the local social services districts.
viii. The Medicaid Cancer Treatment Program (MCTP) – In order to be eligible for this program, clients must be screened by agencies participating in the New York State Cancer Services Program. For a list of participating local organizations, check the NYSDOH website at

In MCTP, uninsured people with income up to 250% of the federal poverty level who are not Medicaid eligible can receive full Medicaid benefits, including medically necessary prescription drugs and transportation, for as long as they need cancer treatment. The MCTP is codified at N.Y. Soc. Serv. L. §366(4)(v).

ix. Medicare Savings Programs (MSP) - this catch-all term refers to three separate Medicaid programs, QMB, SLMB and QI-1.  These programs help Medicare recipients with incomes up to 135% of poverty pay their Medicare premiums, and at lower income levels, other cost-sharing obligations. N.Y. Soc. Serv. L. §367-a(3)(a), (b) and (d). These programs also automatically qualify recipients for the Medicare Part D Low Income Subsidy, which significantly reduces out-of-pocket costs for prescription drugs.

c. Sources of Sub-regulatory law

i. Administrative directives governing all these programs are posted on the NYSDOH website at
ii. Other valuable sources of state policy for local district implementation of the Medicaid program include:

I. The Medicaid Reference Guide (MRG)
II. The Medicaid Provider Manuals
III. The Medicaid Update

These publications are available on the NYSDOH website at:

II. Financial Eligibility for Medicaid in New York

a. Eligibility Categories. Different population or eligibility categories are subject to different income and resource levels. Federal law mandates services only to the “deserving poor” – children,
caretakers, the elderly and the disabled. New York uses state only dollars to extend services to single adults and childless couples as well, although at lower income levels. See HRA Chart.
b. Medicaid Budgeting. Medicaid budgeting rules are different for different eligibility categories. Budgeting rules draw from those used for cash assistance programs – elderly and disabled
applicants use SSI-related budgeting, caretakers and children use AFDC related budgeting. See NYS Medical Assistance Reference Guide, Sections I & II.  Applicants who qualify for both SSI and AFDC-related budgeting have the right to choose the most favorable budgeting.

i. Household Size – SSI-related household size is either one or two (depending on whether the applicant lives with a spouse, whether the spouse receives SSI income, whether there are children and spousal income exceeding certain levels). Household size for all other categories is the number of persons in the household who are applying for Medicaid (excluding any PA/SSI recipients) AND/OR are legally responsible relatives of the applicant.
ii. Deductions from Income and Resources. All income from all members counted in house hold size is used to determine eligibility. Deductions are taken from gross income and vary depending on the applicant’s category. Resources are also counted for all of the family members who are counted in household size, and the resource deduction rules likewise vary by category. See MRG, Sections I & II.
iii. Transfers of Resources. For Community Medicaid services, which include home care, personal care CDPAP and Medicaid assisted living programs, there is no penalty for transfers of assets made prior to applying for Medicaid. 

However, applicants for Institutional Medicaid, which includes not only nursing home stays but also communitybased services provided under waivers that require
participants to qualify for institutional care (i.e. the Lombardi, TBI, the Nursing Home Transition and Diversion Waiver, and OMRDD waiver programs), there is a penalty period in which the applicant is disqualified if a transfer was made within five years before long term care services begin or the application is filed whichever is later.

Exceptions to the transfer penalty include circumstances where application of the penalty would result in undue hardship, and transfers of the applicant’s home to a spouse, or a disabled child who has cared for the transferor for at least two years, or a sibling with equity interest who has lived in the home for at least one year.

c. Spend down – Federal law allows states to use spend down to extend Medicaid to “medically needy” persons in the federal specified categories (children, caretakers, elderly and disabled people) whose income or resources are above the eligibility level. See 42 USC § 1396(a)(10)(ii)(XIII). Under spend down, applicants in New York’s Medically Needy program can qualify for Medicaid once their income/resources, minus incurred medical expenses, falls below the specified level. Spend down is not available to single adults and childless couples.

Spend down rules:

i. Need only incur medical expenses – not actually pay bills.
ii. Expenses can be incurred on behalf of anyone in the household.
iii. Medicaid with spend down is certified for a period of between one and six months – depending on district practice.
iv. For inpatient hospital bills, Medicaid requires recipients to be responsible for SIX months of income spend down before bills are paid by Medicaid.
v. Paid expenses cannot be carried over into the next budgeting period– unpaid expenses can
vi. New applicants can use old bills, as long as the bill is still viable
vii. Expenses that can be counted include:

a. Medicare & other insurance cost-sharing
b. Expenses for medical and remedial services NOT covered by Medicaid
c. Expenses paid for by public non-Medicaid funded programs (including EPIC, ADAP, OMH)
d. Expenses for medical and remedial that ARE covered by Medicaid

d. Retroactive Medicaid – Medicaid can be retroactive for up to three months before the month of application, as long as income and resources were within the allowed limits during those months.   Applicants who those qualify for use of spend down, can use Medicaid to pay or reimburse payments for medical expenses during those months as long as past or current medical bills met the spend down amount.

III. Proof of Citizenship or Qualified Immigration Status

a. Citizenship. The Deficit Reduction Act of 2006 imposed strict citizenship & identity documentation requirements on states. 

i. Although NY had always required proof of citizenship, the new federal rules have made documentation more complicated.
ii. Citizen applicants for Medicaid in NY must now two different documents to prove citizenship and identity, unless they can produce either a US passport or a certificate of Naturalization or Citizenship.
iii. In addition, eligibility workers must now note in the file that hey have seen the original documents as opposed to copies. For a list of the documents that will satisfy the requirements, see 08 OHIP/INF-1 and GIS 08 MA/009.
iv. Only pregnant women, recipients of SSI or Medicare and children in foster care are exempt from these citizenship documentation requirements

Immigration Status. Following the class action Aliessa v. Novello, 96 NY2d 418,(201), NYS provides both Medicaid and FHPlus to all “qualified immigrants.” See GIS 09 MA/009. New York State
residents can qualify for CHPlus, PCAP and Emergency Medicaid regardless of immigration status.

Qualified immigrants include:

i. Lawful permanent residents
ii. Conditional entrants
iii. Persons paroled into the US for at least one year
iv. Certain battered aliens and their parents or children
v. Refugees and Asylees
vi. Immigrants whose deportation has been withheld
vii. Qualified aliens on active duty in the US or honorably discharged, and their spouses, widows and dependent children
viii. Persons permanently residing under color of state law (PRUCOL). For clarification on establishing PRUCOL status see 08 INF-01 and 08 INF-04.

IV. Special Attention to Recent Changes in Eligibility Rules  

The Legislature approved a series of changes to state law in 2007 and 2008 that make it easier to qualify for public health insurance. Not all
county Medicaid workers will be familiar with the new rules. As economic hard times put more fiscal pressure on state and local government, it will be more important than ever to monitor the eligibility
determinations our clients receive.

a. Elimination of the Transfer Sanction for Single Adults and Childless Couples - Prior to April of 2008, single adults and childless couples were subject to one year of Medicaid ineligibility as a penalty for any transfers of non-exempt resources for less than fair market value in the twelve month period prior to the Medicaid application date, even when the Medicaid applying for Community Medicaid as opposed to Institutional Medicaid.

Effective April 1, 2008, single adults and childless couples are no longer subjected to transfer penalties when applying for community Medicaid. N.Y. Soc. Serv. L. §366(1)(a)(1),(8) as amended by L. 2008, c. 58.

b. Elimination of the Drug and Alcohol Sanction - As a throw-back to Medicaid’s original link to eligibility conditions for welfare programs, single adults and childless couples in New York were also subject to Medicaid sanctions (loss of Medicaid eligibility) for non-compliance with the drug and alcohol screening and treatment requirements for cash assistance. 

Effective April 1, 2008, drug/alcohol screenings and treatment is no longer a condition of Medicaid eligibility for any applicants or recipients, including single adults and childless couples. See N.Y. Soc. Serv. L. §366(1)(a)(1),(8) as amended by L. 2008, c. 58; GIS 08 MA/013.

c. Higher Resource Levels

i. Significant jump for regular Medicaid - Effective April 1, 2008, asset levels for all applicants to Medicaid, including single adults and childless couples, were raised to the same asset level allowed for applicants to the FHPlus program.  Households of one can now have $13,050 in savings and still qualify for Medicaid. The new asset level for households of two is $19,200. N.Y. Soc. Serv. L. §366(2)(a)(4) as amended by L. 2008, c. 58; GIS 08 MA/013.
ii. Elimination of Asset Test for MSP Programs - Effective April 1, 2008, the asset test was removed from the Qualified Medicare Beneficiary program (QMB) and the Specified Low Income Medicare Beneficiary (SLMB) program. The Qualified Individuals-1 (QI-1) program already disregards resources. See N.Y. Soc. Serv. L. 367-a(3)(a)(d), as amended by L. 2008, c. 58.

d. Higher Income Levels

i. Medically Needy Levels - As a result of litigation filed in 2005 (Blair v. Novello), income levels for the Medically Needy were raised to match the income level specified for the SSI
program in New York. This change took effect in January of 2008.
ii. Single Adults & Childless Couples - Effective April 1, 2008, income levels for single adults and childless couples were raised and standardized across the state. All single adults and childless couples applying for Medicaid should now be governed by the same income test, regardless of their county of residence. N.Y. Soc. Serv. L. §366(1)(a)(1),(8) as amended by L. 2008, c. 58.
iii. Child Health Plus - In 2008, the Legislature approved an expansion to New York’ CHP program to 400% of poverty with state only dollars (waiver request pending). The new levels became effective on September 1, 2008. N.Y. Pub. Health L. §2511, as amended by L. 2008, c. 58. Most children in the expansion group (incomes between 250 and 400% of poverty) who lose employer related health coverage are subjected to a six month waiting period before then can enroll in CHP. Exceptions include:

i. Children under the age of five
ii. Children for whom employer coverage cost more than 5% of the family’s income
iii. Children who lost coverage when COBRA expired

e. Other Significant Eligibility Expansions

i. Family Health Plus Buy-in Program - In 2007, the Legislature created a program authorizing the Commissioner of Health to allow employers and unions to buy in to FHP, and then offer all of the program’s benefits to their employees or members, regardless of income. The employer or union pays at lease 70% of the premium with the State paying the employee’s share of the premium through a newly created Premium Assistance Plan. N.Y. Soc. Serv. L. § 369-ff. See also 08 OHIP/ADM-1. 

The FHPlus program is not open to individuals. The only entity approved by the Commissioner for participation to date has been Labor Union 1199.

Although this program has started small, some see it as one of the first steps toward universal coverage in New York, as it taps into new public health funding by brining employer contributions into public health insurance.

ii. Former Foster Children Eligible up to Age 21 - Effective January 1, 2009, former foster children who were part of the foster care system on their 18th birthday will be eligible for Medicaid up to age 21. The legislature passed this expansion as part of the 2008 budget and made it contingent upon federal financial participation. See N.Y.Soc. Serv. L. §366 (1)(a)(3-a), added by L. 2008, c. 58.


Download the PDF: Medicaid 101

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