This fact sheet is intended to give Navigators, Assisters and Certified Application Counselors an idea of the questions and informational needs that people with disabilities may have about Medicaid when they are looking into purchasing private insurance in the Marketplace*
Click here for a pdf version of this Fact Sheet
Q1. What is Medicaid?
A. Medicaid provides health coverage for low-income people, including people with disabilities. The program covers all low-income adults below a certain income level. Medicaid is a joint federal-state program that has existed for many years. The federal government establishes basic guidelines for Medicaid’s operation, but each state also has considerable discretion to make rules on eligibility and the availability, scope and length of specific Medicaid services. Most Medicaid has no premiums. Co-pays do not exceed $3.00, except inpatient hospital stays, which are $25. Providers cannot deny services due to inability to pay. Medicaid is the single greatest source of the long-term services and supports (LTSS) needed by many people with disabilities and chronic conditions; Medicare does not pay for LTSS.
Q2. How do I qualify for Medicaid?
A. New York has chosen to increase the income and asset limits for its Medicaid program for certain populations. Many more low income people under age 65 who do not have Medicare qualify for expanded Medicaid. This includes people on Social Security Disability who do not yet have Medicare. Even if you were told you didn’t qualify for Medicaid in the past, you may qualify under these new expansion Medicaid rules that do not require you to fit into traditional coverage categories and allow for higher income and asset levels. Check the chart here to find out if you might qualify for expansion Medicaid, which is based solely on income and family size. If you qualify, you can make up to $16,105 a year for 1 person ($32,913 for a family of 4). Medicaid will provide free or low-cost health care for individuals or families.
Unfortunately, you normally do not qualify for expanded Medicaid if you are over age 65 or receiving Social Security Disability and have Medicare. The old rules also apply if you are receiving Public Assistance or Supplemental Security Income. Your income and assets must fall below and remain under certain maximums
- If your income is more than 100% of the federal poverty level — $11.670 a year as a single person or about $23,850 for a family of 4 and you do not have Medicaid, you will be able to buy a private health insurance plan in the Marketplace and you may qualify for advance premium tax credits and/or cost-share reductions based on your household size and income.
Q3. How do I apply for Medicaid?
A. If you qualify for expanded Medicaid, you can apply online through the New York State of Health portal at nystateofhealth.ny.gov. A Navigator can assist you with the online application. NY State of Health will determine your eligibility for any insurance affordability program that you qualify for, including Medicaid and private health plans with premium assistance and/or cost-sharing reductions. After you have completed the online application, the site will tell you which programs you qualify for. You can also apply by calling NY State of Health at 1-855-355-5777 Monday-Friday 8AM – 8PM, Saturday 9AM – 1PM (TTY: 1-800-662-1220).
People who do not qualify for expanded Medicaid must apply through their local Medicaid office. NY State of Health will refer you to the Medicaid office if your answers on the application indicate that you do not qualify for expanded Medicaid. People who want waiver services must also apply through the Medicaid office whether or not they qualify for expanded Medicaid. The Marketplace will also refer you to the local Medicaid office if you qualify for specific Medicaid programs for non-expansion populations that allow higher income and resource limits. These include the Medicaid spenddown program and the Medicaid Buy-In for Working People with Disabilities (MBI-WPD). . For more information, see our MBI-WPD fact sheet here.
Q4. Can I apply for Medicaid after February 15, 2015 when the period of open health insurance enrollment ended?
A. You can apply for and enroll in Medicaid or Child Health Plus (CHP) (health insurance for children) at any time of year. There is no limited enrollment period for either program. If you qualify for Medicaid, your coverage will take effect retroactive to the first of the month when you apply (and up to three months prior if you have medical bills and qualified for Medicaid during those months). For Child Health Plus, coverage starts on the first of the following month if you apply by the 15th of the prior month and have paid your premium prior to the requested effective date. Once you qualify for these programs, you must recertify your continuing eligibility each year. You will have to indicate that key factors such as your income, your family size, or your disability remain within the guidelines. If upon redetermination you are found not eligible to continue on Medicaid or Child Health Plus, this is a loss of healthcare coverage that triggers a “special enrollment period,” and you can apply for Marketplace coverage outside of of the open enrollment period.
Q5. I am not eligible for Medicaid, but I have a daughter who is autistic. Would she qualify for Medicaid?
A. Medicaid income limits are higher for children than for adults, so your child may qualify for Medicaid even if you do not. The Child Health Plus (CHP) program also provides low-cost health coverage to children in families that earn too much money to qualify as a unit for Medicaid. The CHP benefit is more limited tha Medicaid’s. CHP does cover medically necessary services for the screening, diagnosis, and treatment of autism spectrum disorder. Since the income qualification levels for CHP coverage are higher than the qualification levels for expansion Medicaid, it is possible for one or some household members to qualify for Medicaid or CHP as children, while the adult family members will be above their own expansion Medicaid income threshold. In such a case, the other adult family members are likely to qualify for Marketplace insurance with premium subsidies and/or cost-sharing reductions. When you fill out an application for the Marketplace, the site will tell you which programs you and your family qualify for. If it looks like anyone is eligible for CHP, they will be required to select a CHP managed care plan. The Marketplace administrator will let your plan know that you have qualified so that a premium notice can be sent to your household.
Q6. If my child with a disability qualifies for CHP, what health benefits will she be eligible to receive?
A. The services covered through CHIP are different in each state, but all states provide coverage that includes well-child care, physical exams, immunizations, diagnosis and treatment of illness and injury, x-ray and lab tests, outpatient surgery, emergency care, prescription and non-prescription drugs if ordered, inpatient hospital medical or surgical care, short-term therapeutic outpatient services (chemotherapy, hemodialysis), inpatient and outpatient treatment for alcoholism and substance abuse, and mental health, dental care, vision care, speech and hearing, durable medical equipment, emergency ambulance transportation to a hospital, and hospice.
Q7. I think I am eligible for Medicaid, but I would rather buy a plan in the Marketplace to ensure that I can see the doctor who is knowledgeable about my disability. May I buy a health insurance plan through the Marketplace?
A. If you’re eligible for Medicaid, you already have what is considered “minimum essential coverage” and would not be eligible for the Marketplace savings programs such as the premium credit or any cost-sharing reductions – you would have to pay the full, unsubsidized premium for coverage. You would benefit most financially from enrolling in Medicaid rather than buying private health coverage. A Marketplace plan will be more expensive than Medicaid and usually offers a more limited package of benefits. Keeping your own experienced providers is naturally a concern for you. You must usually join a managed care plan if you have Medicaid in New York. Ask your providers if they accept any of the Medicaid managed care plans. You can also get this information on the NY State of Health portal or on the plan websites.
Q8. I am currently being treated for cancer and require regular lab tests. If I am eligible for expansion Medicaid, what health benefits will I get?
A. The Affordable Care Act requires states that are expanding their Medicaid programs to provide an Alternative Benefit Package (ABP) that includes a comprehensive bundle of items and services, known as Essential Health Benefits (EHBs) to people who are newly eligible for Medicaid. New York’s ABP is identical to its traditional Medicaid package except that the ABP does not include long-term nursing home care. EHBs must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Also, a full range of preventive tests within the EHB categories must be provided without cost sharing. ABPs must also comply with the Mental Health Parity and Addiction Equity Act (See Fact Sheet #7). In addition, all children under 21 who are enrolled in an ABP must receive “Early and Periodic Screening, Diagnostic and Treatment (EPSDT), including pediatric oral and vision services. ABPs must also offer family planning services and supplies, federally qualified health clinic and rural health clinic services, and non-emergency medical transportation.
Q9. I have multiple medical conditions and disabilities for which I need care. Will Medicaid cover the services I need?
A. Medicaid has limitations on when, how, and for how long certain services are covered. For example there is a 20-visit annual limit on physical, speech, and occupational therapy visits. Rehabilitative and habilitative services are part of the required Essential Health Benefits package. Therefore, physical, occupational, and speech therapy are now covered not only to help improve a person’s condition, but also when the treatment’s sole purpose is to avoid pain and slow down functional loss. However, expensive and medically necessary individualized durable medical equipment such as certain power wheelchairs might not be covered.
New York has “waiver” programs for people with Medicaid that offer services not normally covered by Medicaid, such as service coordination, independent living skills training, or home modifications. The purpose of this coverage is to enable individuals to remain in the community who would otherwise have to enter a nursing home. New York Medicaid waivers are Traumatic Brain Injury (TBI), Nursing Home Transition and Diversion (NHTD), Care at Home (CAH) waiver for children with special needs, and Office for People with Developmental Disabilities (OPWDD).
Q10. What can I do if I am denied Medicaid coverage and I disagree with the decision?
A. All state Medicaid agencies and the NY State of Health Marketplace have existing fair hearing and appeal processes. NY State of Health handles these for the expanded Medicaid population, and the Medicaid office handles them for those who do not qualify for expanded Medicaid. The Marketplace also hears appeals on premium and cost sharing subsidies.
Q11. If ultimately I am found ineligible for Medicaid, do I have to start the Marketplace application process all over again? What if the open enrollment period is over by the time I get my Medicaid determination?
A. If you do not qualify for Medicaid, the Marketplace will assess you for premium and cost sharing subsidies. If your income goes down later, you can come back and update your application, and the Marketplace can give you a Medicaid eligibility determination. You can update your application at any time of the year to get Medicaid. If found eligible, your coverage will be retroactive to the first of the month when you were found eligible. If you have medical bills from the previous three months and were Medicaid eligible for three months, you can get Medicaid for those months. If you do not qualify for Medicaid but your Marketplace application is erroneously delayed by the Marketplace, you may qualify for a Special Enrollment to get health insurance, including premium and cost share reductions, past the usual open enrollment period.
* Written for New York by Center for Independence of the Disabled, NY