Medical Assistance: Medicaid

Who is eligible for medical assistance (Medicaid)?
What medical services are paid for by Medicaid in New York State?
Medicaid Managed Care Availability
How can I apply for Medicaid?
What do I need to apply?
Am I eligible for Medicaid?
What is Transitional Medical Assistance?
What is Spend Down/Provisional Medicaid?
Are there co-pays for this program?

Who is eligible for medical assistance (Medicaid)?

Do you or your family lack health insurance coverage? You may be eligible for medical assistance if you receive public assistance, Supplemental Security Income (SSI), or if you meet income, resource, age or disability criteria. There are special programs to help if you are pregnant or have a child. If you are pregnant, a worker at the clinic or hospital you are using for prenatal care may assist you in applying for Medicaid. If you have a child, he/she may be eligible for children's Medicaid, which provides the same benefits as Medicaid.

What medical services are paid for by Medicaid in New York State?

  • inpatient and outpatient care in hospitals
  • physician services
  • clinic services
  • dental care (treatment and preventative services)
  • drugs (prescription and non-prescription) and smoking cessation products
  • eyeglasses
  • nursing home care
  • medical equipment (wheelchairs, walkers, etc.)
  • personal care/long term home health care
  • domiciliary care facilities
  • child teen/health program
  • prenatal care
  • transportation to medical appointments
  • family planning
  • laboratory and X-ray services
  • psychiatric hospitalization and mental health services
  • treatment in facilities for the mentally retarded and developmentally disabled
  • health insurance and Medicare premium payments

Medicaid Managed Care Availability

Medicaid Managed Care is mandatory in Madison County through Fidelis at 1-888-343-3547 or United Healthcare at 1-800-339-5380. Assistance is available through NY Medicaid Choice, Maximus at 1-800-505-5678.

How can I apply for Medicaid?

No interview is necessary. Request an application be mailed to you by calling 366-2211. An interview may be scheduled if you would like one. Applications are also available from:

  • Planned Parenthood Clinics, Oneida, NY (only Family Planning applications): (315) 363-3950
  • Mohawk Valley Perinatal Network: 1-877-267-6193 or 315-732-4657
  • Maternal Child Care Health Center: 315-366-2361
  • Madison County Office for the Aging, Inc.: 315-697-5700 (MSP application)

What do I need to apply?

  • Proof of identity
  • Social Security numbers for applying household members
  • Proof of citizenship or alien status*
  • Recent paycheck stubs (if you are working)
  • Proof of your income from sources like Social Security, Supplemental Security Income (SSI), Veteran's Benefits (VA), retirement
  • Any bank books and insurance policies that you may have
  • Proof of where you live, like a rent receipt or landlord statement
  • Insurance benefit card or the policy (if you have any other health insurance)
  • Medicare Benefit Card

*NOTE: Medicaid coverage is available, regardless of alien status if you are pregnant or require treatment for an emergency medical condition. A doctor must certify that you are pregnant or had an emergency and you must meet all other eligibility requirements.

Am I eligible for Medicaid?

For more information regarding income and resource guidelines for medical assistance programs visit

What is Transitional Medical Assistance?

Transitional Medical Assistance is a program that provides continued medical assistance coverage to people who become ineligible for family assistance and who have a dependent child under the age of 21 living with them. Transitional MA benefits are available for 12 months to those who lose family assistance due to:

  • new employment
  • increased earned income
  • loss of earned income disregards

What is Spend Down/Provisional Medicaid?

In New York State, if you spend a lot on doctor’s visits, prescriptions, insurance premiums or other healthcare services, but have income over the Medicaid limits, you may still qualify under the Medicaid Spend Down Program (also called the Medicaid Excess Income Program). In other words, you will need to show that you spend enough on health care that it puts your income down below the Medicaid limits.

When you meet your spend down on a monthly basis, you can receive outpatient services within the month you meet it. You can also receive inpatient services if you meet your spend down for six (6) months at a time. You do not need to meet your spend down each month, only the months that you will need it.

There are a number of ways to meet your spend down, such as with unpaid or paid medical bills you have incurred or paying it directly to the Department of Social Services. Any specific questions should be directed to a Medicaid worker.

Are there co-pays for this program?

Medicaid has co-pays for certain services they provide. If you are unable to pay these, your provider can bill you, but you are still responsible for them. Children under 21 and pregnant women (until 60 days postpartum) are exempt from paying co-pays.

The following services are subject to a co-pay:

  • Clinic visits (hospital-based and free-standing Article 28 Health Department-certified facilities) - $3.00;
  • Laboratory tests performed by an independent clinical laboratory or any hospital-based/free-standing clinic laboratory - $1.00 per procedure;
  • X-rays - $1.00 per procedure
  • Medical supplies including syringes, bandages, gloves, sterile irrigation solutions, incontinence pads, ostomy bags, heating pads, hearing aid batteries, nutritional supplements, etc. - $1.00 per claim;
  • Inpatient hospital stays (involving at least one overnight stay - is due upon discharge) - $25.00;
  • Emergency room - for non-urgent or non-emergency services - $3.00 per visit;
  • Pharmacy prescription drugs - $3.00 brand name non-preferred, $1.00 brand name preferred, $1.00 brand name when less than generic, $1.00 generic;
  • Non-prescription (over-the-counter) drugs - $0.50.

Co-pay Maximum

You are responsible to pay a maximum of up to $200 in a co-pay year.  Your year begins on April 1 and ends March 31 each year.  If you reach your maximum of $200, a letter will be sent to you exempting you from paying Medicaid co-payments until April 1.
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