| Medicaid
What is Medicaid?
Medicaid is a health insurance program administered by the City
of New York's Family Independence Administration that pays the medical
bills of individuals and families who cannot afford medical care.
Medicaid pays registered providers directly for the following services:
- Hospital in-patient services
- Hospital out-patient services
- Doctors' services
- Laboratory tests
- Eyeglasses
- Hearing aids
- Transportation when essential to obtain medical care
- Nursing home services
- Home care services (personal care and housekeeping)
- Prescriptions
- Dental services
Is Medicaid accepted everywhere?
No. Not all doctors, pharmacies or laboratories accept Medicaid.
If you receive services from a doctor, pharmacy or lab that does
not accept Medicaid, the bills will NOT be covered. You will have
to pay for that service yourself. Ask your doctor or other service
providers if they accept Medicaid.
How do I get a Medicaid Benefit Identification Card if
I have SSI or Public Assistance (PA)?
People who get PA but have not received a permanent plastic Medicaid
Benefit Identification Card should contact their PA worker to get
one. The same card is also used as a swipe card to access your monthly
PA cash benefits and Food Stamp credit. People who get SSI have
to give their SSI award letter or SSI Referral and Notification
Form (DSS-2474) to their nearest Medicaid Office. The Medicaid Office
will give them a Temporary Medicaid Authorization Form (DSS-2831A)
and arrange for a permanent plastic Medicaid Benefit Identification
Card.
NOTE: The Medicaid Benefit Identification Card can also be called
a Medicaid Card or Benefit Card.
How do I get a Medicaid Benefit Identification Card if
I have Public Assistance through HIV/AIDS Services Administration
— HASA (formerly DASIS)
If you receive Public Assistance through the HIV/AIDS Services
Administration (HASA), you will receive a Benefit ID card automatically
as long as you ask for Medicaid at the time of application. If you
do not receive a card, speak to your case manager at HASA. If you
have a case manager at HASA, but you do not receive Public Assistance
through them, your case manager needs to complete a Medicaid application
for you.
If I don't receive PA or SSI, how do I apply for Medicaid?
The application procedures for single persons and families are
the same, except that families must give documentation for each
person in the household. Single people and families who do not get
SSI or Public Assistance benefits may still get Medicaid coverage.
Apply by going directly to your local Medicaid office.
You should call first to make an appointment. The Eligibility Specialists
can tell you over the phone a list of documents to bring to the
appointment. They will help you fill out the application in person.
What if I am homebound?
Medicaid applications can be filled out in your home if you are
too sick to travel. A Medicaid worker will come to your house to
interview you. You can make an appointment for a home visit by calling
the HRA InfoLine at 1-877-472-8411. It may take several weeks to
get an appointment. You do not have to apply in person. A friend
can go to the local Medicaid office and apply for you as long as
you give them all the documentation that Medicaid asks for.
What do I need for the interview?
The Medicaid worker (sometimes called an Eligibility Specialist)
will have the application form for Medicaid and a Disability Interview
form. These forms will be completed by the worker. You must have
a work history narrative. This can be a list of employers and jobs
during the last 5 years. A Medical Report for Determination of Disability
has to be filled out by your doctor.
You need to bring these documents to the appointment:
- SSD award letter (to prove your income and residence)
- Birth Certificate, Passport or Baptismal Certificate
- Social Security Card (if you do not have your Social Security
card, you can use your SSD Award Letter to prove your Social Security
number)
- Diagnosis letter from your doctor (you can use your SSD Award
Letter if it shows an AIDS or AIDS Related Complex diagnosis)
- Green Card and/or Naturalization papers or other INS documentation
proving alien status
- Lease (if your apartment is in your name) or if lease is in
a roommate's name, a letter from him or her telling about your
living situation. In this letter it should say that you share
the rent and utilities equally (give the amounts) and food is
bought and prepared separately. You will also have to have a copy
of the lease or utility bill showing your roommate's name.
- Recent rent receipt or above letter
- Recent electric and/or gas bill
- Recent phone bill
- 2 most recent checking account statements
- Savings account statements or savings passbook showing activity
for 24 months
- Recent health insurance premium statement if you have health
insurance. Medicaid can pay this bill for you or it will help
reduce your Medicaid Spenddown (see below)
- Proof of residence for each child — school records or
physician's or clinic's statement
- Proof of citizenship or alien status for each child —
birth certificate or INS documentation
A Medicaid worker will go over the application and documents with
you during the appointment. The worker must see the original documents
but has no reason to keep them. Ask that they copy all your papers
and have the originals returned to you.
What happens after I apply?
After Medicaid gets your completed application they must, by law,
reject or approve it within 30 to 60 days. If they need additional
information, the worker will contact you by mail. You should get
a permanent plastic Medicaid Benefit Identification Card in the
mail two weeks after approval.
How can I use my Medicaid coverage faster?
If you have received the approval notice for Medicaid but need
medical help right away, you can get a Temporary Medicaid
Authorization Form (DDS-2831a). You can use this form instead
of the permanent Medicaid card. You can get it on the same day your
application for Medicaid is approved. If you are going to get Medicaid
through Public Assistance or a HASA case, the temporary Medicaid
Authorization form has to come from the Income Support or HASA worker.
A Medicaid worker has no control over a Medicaid case opened by
Income Support or HASA. If you have Medicaid through SSI or directly
through Medicaid, the Temporary Authorization Form has to be issued
through Medicaid.
I have SSI. How do I get a Temporary Medicaid Authorization
Form?
A Medicaid worker can give a Temporary Medicaid
Authorization form to anyone who gets SSI and has an SSI Award Letter
or an SSI Referral and Notification Form. The Referral
and Notification Form must show that you are eligible for SSI on
the same date, or earlier. You can get the Temporary Medicaid Authorization
on the same day that you bring the Notice from SSI into the Medicaid
office.
What if I have old medical bills?
When you apply for Medicaid, Public Assistance or a rent supplement
from HASA, there is a question in the medical section of the blue
and white application that asks you to, "Indicate if you or anyone
who lives with you who is applying has paid or unpaid medical bills
for the three months preceding the month of this application."
If you have any paid or unpaid medical
bills from service providers who accept Medicaid, you should
answer "YES" to this question. This will allow Medicaid to grant
you coverage for up to three months prior to the month in which
you apply.
Any unpaid medical bills from sources that accept
Medicaid for up to three months prior to the month of application
can be sent back to the service provider with your Medicaid number.
The provider can then request payment from Medicaid. You can request
reimbursement for any paid medical bills from up
to three months prior to your application date from:
Medicaid Out-of-Pocket Reimbursement Unit
330 West 34th Street, 9th floor
New York, NY 10001
212/643-3386
With your request, you should include the original bills (make
copies for yourself) and your Medicaid number. If you have already
paid the bill and want reimbursement, include proof of payment.
If you did not answer yes to the question on the application, and
if you discover that you have bills that need to be taken care of,
you will need to get the Medicaid Out-of-Pocket Reimbursement Unit
(address above) to roll back your Medicaid coverage. Remember:
It is much easier to get credit for the bills at
the time of your application appointment. Be sure to keep copies
of the bills for the appointment. Be sure to keep copies of all
your letters to Medicaid and documents.
Tip: Be sure to write down the name and telephone
number of the Medicaid worker who is working on your application.
Ask if he or she needs any more information. Unless you are given
a Request for Documentation/Information Form, you application is
complete. Ask the Medicaid worker to call you if he or she finds
out after the interview that more information is needed. You must
give the missing information by a certain date.
What is the Surplus Income/Spenddown Program?
People who don't have SSI or PA and don't receive PA through HASA
can sometimes get Medicaid with a "Spenddown." The Medicaid Surplus
Income/Spenddown Program is a program for disabled people who have
income before taxes that is above the Medicaid income limit. The
limit is $700 a month for a single person, and
$900 for a household of two, as of 2005. The income
limit increases with the number of people in the household. This
program allows people whose monthly incomes are above the limits
to spend the difference between what they earn and the income limit.
The "surplus" income (the difference between your monthly income
and the Medicaid income limit) must be spent on
medically related expenses. The income levels for
Medicaid can change and usually do change every twelve months.
How does it work?
The program works very much like an insurance deductible. You get
Medicaid coverage in any month that you incur medical bills equal
to or greater than the surplus (spenddown amount). "Incur" means
that you have a bill for a medical expense; it does not mean that
you have paid the bill. You can use paid and unpaid medical bills
to meet your spenddown amount. Medicaid will not pay them. However,
Medicaid will pay your other medical bills after
you have met the spenddown amount in that month as long as the bills
are from a Medicaid provider (a doctor or other medically related
service that accepts Medicaid as payment for its services).
Give me an example.
Your monthly income is $100 over the allowable Medicaid income
limit. The $100 becomes your monthly income surplus amount. In any
month that you submit to Medicaid any medical bills that add up
to at least $100, Medicaid will activate your coverage for that
month.
When you first apply for Medicaid, they will give you credit towards
your monthly income surplus spenddown amount (for this example the
spenddown amount is $100) using medical bills incurred within three
months prior to the month of application. For example, let's say
that you apply for Medicaid on August 1 and you have a $600 medical
bill dated June 15. Because that bill is dated within three Months
prior to the month of application for Medicaid, the program will
give you six months of active Medicaid coverage for June through
November. You would not have to submit medical bills again until
December. You are responsible for the payment of the bills you submit.
Medicaid will not pay them.
Note: It is best to send or bring all bills to
Medicaid as early in the month (any month that you need coverage)
as possible in order to avoid a delay in active coverage.
How is the Surplus/Spenddown amount calculated?
In determining the surplus, Medicaid allows certain income deductions.
There is a standard $20 disregard on your monthly income. There
is also a deduction for any monthly private health insurance premium
you pay.
| Example: |
| Monthly Income |
$830 |
| Standard Disregard |
-20 |
| Total |
810 |
| Monthly Health Insurance Premium |
-50 |
| Monthly Income (after deduction of incurred medical
expenses) |
760 |
| Maximum Monthly Medicaid Income Limit for 1 |
700 |
| Surplus Income/Spenddown Amount |
$60 |
What if I become hospitalized?
If you have Medicaid with a spenddown and you are hospitalized,
Medicaid will pay the entire hospital bill EXCEPT FOR 6 TIMES THE
MONTHLY SPENDDOWN AMOUNT. In the case above, you would be responsible
for paying $360 (6 months x $60) of the hospital bill. If you have
to go back to the hospital within 6 months of your first hospitalization,
you will not incur a second $360 liability. The $360 is the total
6-month liability. If you are hospitalized in the 7th month, you
will incur
a second $360 liability. You will get a 6-month credit and a Medicaid
Benefit Identification Card will be issued for 6 month's coverage.
Full coverage is given even if you are unable to pay the hospital
liability portion. Whether or not you pay your portion of the hospital
bill, Medicaid will still pay its part. The only exception to full
coverage is when the Third Party Health Insurance (TPHI) payment
amount is unknown and a complete budget cannot be calculated by
Medicaid.
How do I get into this program?
People applying for Medicaid are automatically reviewed for the
Surplus Income/Spenddown program. Your Medicaid application packet
must include all paid and unpaid original bills
as far back as 3 months prior to the date of application. Bills
for service that you received earlier than 3 months before the date
of application (for example, 5 months old) can be used for spenddown
credit only if the bill is dated within 3 months of the Medicaid
application.
You automatically have full Medicaid coverage
without a spenddown if you receive benefits through SSI or Public
Assistance.
Does Medicaid pay private health insurance premiums?
Yes. Medicaid will pay the private health insurance premiums of
eligible persons. The idea behind this is that it is cheaper for
Medicaid to pay the premium than to pay for the full cost of medical
service. Medicaid can pay private health insurance premiums directly
to the health insurance company.
If the premium is paid by you, a friend, or a family member, Medicaid
will reimburse the person who paid it. If you do not qualify for
Medicaid, there are other programs that pay health insurance premiums
that you may qualify for. For information about the other programs
and to see if you qualify, please contact the GMHC Advocacy Helpline
at 212/367-1125.
How does third party payment work?
Medicaid needs at least 60 days to pay a health insurance premium.
To avoid losing your health insurance policy because of late payments,
make sure the premium statement is sent to Medicaid as soon as you
receive it. If you are unsure if Medicaid will have time to pay
the bill, call and ask. People on COBRA must make sure of the date
payment is due because they do not get premium statements. If there
is enough time for Medicaid to pay your insurance, the original
premium statement, your Medicaid number and a short letter asking
for them to pay your bill should be sent by Certified/Return Receipt
mail to:
Medicaid
Third Party Health Insurance Services, Room 405
330 West 34th Street
212/630-1158, -1152 or -1155
What if I run out of time?
If there is not enough time for Medicaid to pay your health insurance
premium, someone else can pay it and get reimbursed from Medicaid.
The person who pays the bill can get reimbursed by Medicaid by sending
(to the same address above) a copy of both sides of the canceled
check, a copy of the premium statement and a letter asking to be
reimbursed.
I heard GMHC can pay it for me?
If you are a GMHC client and Medicaid is unable to process the
check to pay your insurance premium on time, they may request that
we pay the premium for you. Medicaid will reimburse us at a later
date. The request must come to us from Medicaid, therefore, you
must first make the request of the Medicaid Third Party Recovery
Unit.
Medicaid managed care on its way
New York State has been changing the way that Medicaid service are delivered
to people. Traditionally, most people on Medicaid have been able to go to
any provider they choose, so long as the medical provider accepts Medicaid.
Now, Medicaid is provided to many people through managed care organizations
with a limited network of medical providers. People on Medicaid managed care
can see providers only if they accept Medicaid AND if they are in the
particular network of the managed care organization. Certain exceptions
exist for some services, including family planning services and methadone
maintenance. Additionally, there are exemptions and exclusions for people in
specific categories, such as people with HIV and people who are on both
Medicare and Medicaid. That means that if you have HIV, you do not have to
join a Medicaid managed care plan right now, but you may do so if you wish.
A special enhanced type of Medicaid Managed Care plan has been created
specifically for persons with HIV: the HIV Special Needs Plans (or SNP’s).
SNP’s are not currently mandatory for people with HIV, but they may become
mandatory in the future. GMHC’s Client Advocacy Managed Care Team publicizes
information and provides guidance about HIV Special Needs Plans.
The Client Advocacy Unit at GMHC is available to assist
you. For more information, please call our Helpline: 212/367-1125,
Wednesdays 2 pm to 5:30 pm. Walk-in services are availableTuesdays and Thursdays, 10 am to 1 pm.
Revised 3/07
© 2007 Gay Men's Health Crisis
|
home 
