Benefit Development Resource Toolkit: Medicaid

Overview

Throughout the following section, links to various web pages are provided for reference. Please note that web page addresses change frequently and while the addresses provided were accurate as of the issuance of this Toolkit, if you are unable to access any of the web pages through the links, please refer to the main NYS Department of Health website at https://www.health.ny.gov/health_care/medicaid/ and navigate to the information you are seeking.

Medicaid is a health insurance program administered by the New York State Department of Health (DOH) through the Local Departments of Social Services (LDSS) (https://www.health.ny.gov/health_care/medicaid/ldss.htm).  Medicaid provides healthcare coverage for people with low incomes, children, people who are aged (65 or older), blind, and/or disabled, and other New York residents who are eligible. Medicaid pays for OPWDD services for New Yorkers with developmental disabilities. 

Medicaid Eligibility

Medicaid eligibility is based on both financial and non-financial factors. Because Medicaid is a needs-based program, individuals must meet certain income and resource requirements to qualify. The primary categories used for individuals served by OPWDD and its provider agencies are:

  • Supplemental Security Income (SSI) Recipients: People who receive SSI and are automatically eligible for Medicaid (see the section on SSI for eligibility criteria)
  • SSI-Related: People who do not receive SSI but are blind, disabled or 65 years of age or older and meet Medicaid eligibility standards
  • Medicaid Spenddown (Excess Income Program): People who have more income than the Medicaid program allows, but who meet other Medicaid eligibility standards
  • MBI-WPD: People who work may be eligible through the Medicaid Buy-In Program for Working People with Disabilities (MBI-WPD), allowing them to earn income above the limits for SSI recipient or SSI-related categories

All these programs are discussed further below. There are standard requirements for Medicaid eligibility; however, programs exist for individuals whose income or resources exceed the standard levels. It is expected that individuals will apply for Medicaid even if they do not appear to qualify based on their income or resources. 

Once an individual or their authorized representative files a Medicaid application, they should use Medicaid enrolled providers because Medicaid only pays for services from such providers. Medicaid will not pay providers that don’t accept Medicaid. 

The timing of benefit-related actions, including applying for benefits and reporting changes, is critical. Any requests or correspondence from the Medicaid district should be addressed immediately. If someone other than the individual themselves is applying for Medicaid and would like to receive correspondence or notices from Medicaid related to the individual’s case, they can request the local DSS add their name and address to the “Associated Name” section of the Medicaid case.  

Benefit development personnel should refer to the Flow Charts at the end of this section concerning individuals without Medicaid coverage and individuals who already have Medicaid. These charts are provided to assist in determining the appropriate actions to take, depending on an individual’s Medicaid status.

Categorical Eligibility: Medicaid and SSI

In New York State, Supplemental Security Income (SSI) beneficiaries are automatically eligible for Medicaid. When SSI recipients apply for SSI, their Medicaid case should be automatically opened in the appropriate district. If Medicaid is not opened or the person is moving from another state, the individual or their representative should bring the individual’s SSI award letter to the LDSS so that Medicaid can be opened. They can also file a one-page application (https://www.health.ny.gov/forms/doh-5104_dd_access.pdf) with a copy of the letter.   

While Medicaid eligibility is automatic for SSI recipients, individuals applying for SSI should also apply separately for Medicaid because SSI applications can take up to 6 months to be processed. SSI payments are not retroactive. SSI payments do not begin until the month after the application is approved. Medicaid, on the other hand, can be retroactive for 3 months. This means that Medicaid can usually be opened prior to an SSI application being approved if they are applied for at the same time. There is also the possibility that a person may be determined ineligible for SSI yet be eligible for Medicaid; therefore, waiting for the SSI decision only prolongs the period for which a person does not have Medicaid coverage.

Categorical Eligibility: Medicaid and Citizenship

In New York State, Medicaid is available to United States citizens and qualified non-citizens. Emergency coverage is also available for undocumented or illegal aliens. The following resources are available to help determine whether a person is eligible:

How and Where to Apply for Medicaid

While each county in New York State has a Medicaid office (LDSS) that is generally responsible for handling Medicaid for people living in their counties, NYS also has an online marketplace called the New York State of Health (NYSoH). OPWDD operates a statewide Medicaid district (District 98), which handles Medicaid coverage for most individuals who live in state-operated residential programs and certain individuals in some nonprofit agency living arrangements, regardless of the county where they live. Where a person should apply depends on different criteria. See the sections below for more information. 
If the person does not receive SSI, the individual or the individual’s authorized representative must file an application with the responsible Medicaid district to obtain Medicaid. If an individual is applying for SSI, it is recommended that the individual apply for Medicaid at the same time since Medicaid can be retroactive for 3 months if the individual is eligible. There is also the possibility that a person will be found ineligible for SSI, but eligible for Medicaid. Medicaid will also cover medical bills for the 3 months prior to the date of the Medicaid application if those bills:

  • are medically necessary; and
  • are for services and in amounts covered by Medicaid; and 
  • are from Medicaid enrolled providers.   
New York State of Health (NYSoH)

Individuals who are receiving, or wish to receive, residential services should apply for coverage at the LDSS (see below) and not through NYSoH. 

New York State of Health is New York State’s online health insurance marketplace, which allows New York state residents to shop for health insurance plans, apply for coverage, and determine eligibility for a subsidy, called an advance premium tax credit (APTC), to offset the cost of purchasing insurance through the marketplace. NYSoH will also determine Medicaid eligibility. 

People who do not need OPWDD residential services can apply for health insurance coverage, including Medicaid, online through NYSoH at: https://nystateofhealth.ny.gov/. Assistance is available by calling 1-855-355-5777, or by contacting an In-Person Assistor (IPA), Certified Application Counselor (CAC) or Navigator. IPAs, CACs and Navigators are trained and certified to assist individuals and small businesses with the online application process. IPAs and Navigators are available in convenient community-based locations in every county, while CACs may work for entities such as hospitals, clinics, providers or health plans.

To find in-person assistance:
https://nystateofhealth.ny.gov/agent/hx_brokerSearch?fromPage=INDIVIDUAL.


District of Responsibility

For people with developmental disabilities, the chart below shows when Medicaid is the responsibility of OPWDD District 98 and when it is the responsibility of the LDSS. This is based on living arrangement and Chapter 621 status. 

Individuals who are Chapter 621-eligible have at least five years of continuous inpatient status in a state facility (i.e., developmental center or psychiatric center) since June 29, 1969. Inpatient status is defined as residential status without discharge or release from the facility/facilities for any period of 90 days or longer.

Responsible Medicaid District

Living Arrangement Chapter 621 Non-Chapter 621
At Home (Living Alone or Living with Others) LDSS LDSS

 

State Operated Residences Chapter 621 Non-Chapter 621
Family Care (SOFC) OPWDD (98) OPWDD (98)
Intermediate Care Facility (SOICF) OPWDD (98) LDSS
Small Residential Unit (SRU) OPWDD (98) OPWDD (98)
Developmental Center (DC) OPWDD (98) OPWDD (98)
Individualized Residential Alternative (SOIRA)) OPWDD (98) LDSS
SOIRA converted from SOICF OPWDD (98) LDSS*

 

Voluntary Operated Residences Chapter 621 Non-Chapter 621
Family Care (ASFC) OPWDD (98) OPWDD (98)
Intermediate Care Facility (VOICF) OPWDD (98) LDSS
Individualized Residential Alternative (VOIRA) or Community Residence (VOCR)  LDSS LDSS
VOIRA converted from a VOCR LDSS LDSS
VOIRA/VOCR converted from a VOICF  LDSS* LDSS
VOIRA converted from a SOIRA LDSS* LDSS

 

*Please note that there are times when individuals who resided in converted residences at the time that they converted, though not Chapter 621-eligible, are the responsibility of District 98 until they move to another residence. This is a limited number of individuals and any questions about Chapter 621 status should be directed to the local Revenue Support Field Office (RSFO).

To apply to OPWDD’s District 98 Medicaid, contact one of the nine OPWDD Revenue Support Field Offices (RSFOs) across the state.

Local Department of Social Services (LDSS)

The following individuals should apply with their Local Department of Social Services (LDSS):

  • Individuals age 65 and older, when age is a condition of eligibility;
  • Individuals whose eligibility is based on being blind or disabled;
  • Individuals who need coverage for community based long term care (CBLTC) services; including those individuals with a need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS);
  • Medicare Savings Program (MSP) enrollees;
  • Medicaid Buy-In for Working People with Disabilities enrollees (MBI-WPD);
  • Former Foster Care youth;
  • Residents of adult homes and nursing homes;
  • Non 621-eligible residents of residential treatment center/community residences operated by OPWDD or the Office of Mental Health (OMH); and
  • Pregnant women 
SSI – Related Application Forms

All Medicaid applicants applying through the local district or through OPWDD District 98 must use the Access NY Health Care application (DOH-4220) . In addition, individuals requesting HCBS Waiver services and individuals requiring care in an Intermediate Care Facility (ICF) or Developmental Center (DC) must also file the Access NY Health Care Supplement A (DOH-4495A).    

Individuals seeking HCBS Waiver services must provide documentation of their current resources. For ICF/DC care, individuals must provide documentation of their resources for 60 months prior to the date of application.

To assist individuals in completing the Access NY application and providing the necessary documentation, the following materials are available:

Types of Medicaid Coverage

It is important to apply for the type of coverage that will pay for the services the person needs and to include all necessary documentation to avoid delays in application processing. 

Individuals Residing in Institutional Settings 

Full coverage (Medicaid Coverage Code 01) is necessary for individuals receiving OPWDD services in institutional settings and requires documentation of resources for the past 60 months. Institutional settings include Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Nursing Facilities (NF), Developmental Centers (DC), and Small Residential Units (SRU). Full coverage pays for all Medicaid covered services and supplies.

Individuals Residing in Community Settings

Individuals residing in the community should apply for Community Coverage with Community-Based Long-Term Care (Medicaid Coverage Code 19 or 21). This type of coverage pays for all Medicaid covered care and services, including adult day health care, Personal Care, private duty nursing, the assisted living program, OPWDD HCBS Waiver services and Care Management.  For this type of coverage, individuals must document the value of their current resources at initial application. This coverage type does not cover long-term care services in nursing facilities and equivalents or services provided in an ICF/IID. Individuals with excess countable income will have a spenddown and the Medicaid coverage code will be 21.

Note:  Community Coverage without Long-Term Care (Medicaid Coverage Code 20 or 22) does not cover services provided in an ICF/IID or OPWDD HCBS Waiver services and is therefore not appropriate for individuals applying for OPWDD services. Medicaid coverage code 22 indicates the individual has a spenddown.

If the Medicaid district gives an OPWDD HCBS Waiver enrolled individual Community Coverage without Long-Term Care (Medicaid Coverage Code 20 or 22), the individual or their representative must request that the coverage type be changed to Community Coverage with Community-Based Long-Term Care (Medicaid Coverage Code 19 or 21).
 

Medicaid Transfer of Assets

When the Medicaid district reviews the type of coverage an individual needs, the district will look at the individual’s resources. If the person transferred non-exempt resources for less than fair market value, this is called a “transfer of assets”. Medicaid presumes that the individual transferred their resources in order to qualify for Medicaid. A voluntary transfer of assets is prohibited when it is made up to 60 months prior to the date the individual applied for Medicaid or at any time after the application date.

When a Medicaid applicant makes a prohibited transfer but is otherwise eligible for Medicaid, a penalty period is imposed. During this penalty period, the applicant is not eligible for the following care and services:

  • Nursing facility services
  • ICF/IID services
  • A level of care provided in a hospital equivalent to nursing facility services

The penalty period starts on the first of the month following the month in which the assets were transferred or the date the person is receiving nursing facility services, whichever is later. The length of the penalty period is calculated by dividing the total uncompensated value of the transferred assets by the average regional rate for the nursing facility services in the region. If the uncompensated value of the transferred assets is less than the regional rate or if the penalty period results in a partial month penalty, that amount will be due to the provider of services.

Transfer provisions do not apply to persons applying for or receiving HCBS Waiver services.
 

Face-to-Face Interviews

Individuals are not required to appear for face-to-face interviews when applying for Medicaid, however, individuals may ask for application assistance from the appropriate LDSS or the local RSFO.

Acceptance Process

After an application is submitted, the Medicaid district will determine whether the individual is eligible and will send a letter notifying the individual of acceptance or denial within 45 days of the date of the application. If a disability determination is required, it may take up to 90 days to determine eligibility.

Medicaid Financial Eligibility: Income and Resources

For Medicaid eligibility determinations through District 98 and LDSS, all income, both earned and unearned , is reviewed to determine if it is available and countable. Certain types of income or a portion of certain income may be disregarded in determining the portion that is “countable”. Countable income is compared to the Medicaid income level for where the person resides (e.g., in a group home, in their own apartment, family care home, etc.). If an amount of countable income is over the appropriate income level, that excess amount is considered available to meet the cost of medical care (spenddown).

Disregards are portions of income (both earned and unearned) that are “disregarded” or excluded from an individual’s income for the purposes of determining Medicaid eligibility. Specifically, the first $20.00 of unearned income is disregarded and is referred to as a general income disregard. If an individual has no unearned income or has unearned income of less than $20.00 per month, the general income disregard or a portion of it is applied to their earned income. In addition, a $65.00 disregard is applied to earned income (for a total of $85.00 in income disregards). Finally, one-half of the remaining earned income is excluded or disregarded, to obtain the individual’s monthly net income. The final net amount is considered “countable” for determining Medicaid eligibility.

Income directly diverted to a supplemental needs trust or a pooled trust is not viewed as income by Medicaid. Income received and then placed into the trust is also not counted as income. However, trust assets distributed to the individual are counted as income.  

Resources are reviewed to determine their availability and value as of the first day of each month for which an individual is seeking or receiving Medicaid coverage. The type of resource determines if it is countable. Not all available resources are counted and, like SSI, certain resources are disregarded in determining the individual’s countable resources.  For more information about disregarded resources, see:
https://www.health.ny.gov/health_care/medicaid/reference/mrg/resindex.pdf, pages 486-492. 

Countable resources are compared to the applicable resource level in determining Medicaid eligibility. 

The most current levels are posted at: https://www.health.ny.gov/health_care/medicaid/ under Medicaid FAQs.

If an individual is married, their spouse’s income and resources may also be considered. If the individual is under 18 years old and is not enrolled/enrolling in the OPWDD HCBS Waiver, their parents’ income and resources will also be considered.

Resource Verification

New York State will verify resource information through an electronic asset verification system (AVS) as part of the application process. Individuals or their representatives must authorize use of AVS when they sign the Medicaid application or recertification. Failure to allow AVS can result in Medicaid being denied. If the individual is not capable of providing consent and signing, a representative can attest to the individual’s incapacity and provide attestation or documentation of their resources (instead of using AVS). 

If an applicant fails to report a resource, and it is discovered through AVS, Medicaid will ask the applicant to verify. Medicaid will use the higher amount (from the applicant or from AVS) when budgeting the resource. Failure to respond to inquiries from Medicaid may result in denial of the Medicaid application or closure of the case.  

A retirement fund owned by an individual is a countable resource only if the individual is not entitled to periodic payments but can withdraw any of the funds. The value of the resource is the amount of money that the individual can currently withdraw. If there is a penalty for early withdrawal, the value of the resource is the amount available after the penalty deduction. Any income taxes are not deductible in determining the value of the resources. If the individual is in receipt of periodic payments, the retirement fund is not a countable resource. Instead, the periodic payments are considered income in the month of receipt.

Budgeting Income

Local social services districts use a budgeting process to determine the countable value of an applicant’s income. Budgeting differs based on the individual’s Medicaid category. The following budgeting methodology applies to individuals who have Medicaid through the SSI-Related category (i.e., individuals who are age 65 or older, blind, or have a disability) and the Medicaid Buy-In Program for Working People with Disabilities. While the budgeting methodology is the same, individuals who participate in the Medicaid Buy-In Program for Working People with Disabilities cannot spend down their excess income to qualify for the program.

  1. Calculate the individual’s countable unearned income:
    • Deduct the $20.00 general income disregard from the individual’s unearned income. If the unearned income is less than $20.00, the remainder of the disregard is subtracted as the first deduction from earned income (see Step
      2.a. below).  This general income disregard is not applicable for a person in a DC, ICF/IID, SRU or nursing home.
    • Deduct health insurance premiums if paid from unearned income.
    • If the health insurance premium is greater than the amount of unearned income remaining after Step 1, the balance of the health insurance premium amount is subtracted from earned income. Refer to Step 2.g.
  2. Calculate the individual’s countable earned income:
    • If the full $20.00 general income disregard could not be applied to the individual’s unearned income (Step 1.a.), deduct the balance of the $20.00 general income disregard from the total gross monthly earnings. Remember, this disregard is not applicable for a person in a DC, ICF/IID, SRU or nursing home.
    • Subtract the $65.00 earned income exclusion from the remaining total gross monthly earnings.
    • If the individual has any impairment-related work expenses (IRWE https://www.ssa.gov/redbook/eng/ssdi-and-ssi-employments-supports.htm# ), deduct those after the $65.00.
    • Deduct one-half of any remaining earned income also as an earned income exclusion.
    • If the individual has blind work expenses (BWE) (https://www.ssa.gov/redbook/eng/blindrules.htm#), deduct those after the one-half deduction.
    • If the individual has an approved Plan to Achieve Self Support (PASS), (https://www.ssa.gov/redbook/eng/ssdi-and-ssi-employments-supports.htm#), deduct the amount placed in the PASS account.
    • If the individual has health insurance premiums that were not fully deducted from unearned income, deduct those.
  3. Add the countable unearned income and countable earned income to calculate the individual’s total countable monthly income.
  4. Compare the individual’s total countable monthly income to the applicable Medicaid income level.

For an SSI-related individual, the amount over the Medicaid income level is the monthly spenddown amount. If an SSI-related individual has earned income from working, they may want to explore eligibility for the Medicaid Buy-In for Working People with Disabilities, which allows individuals to keep Medicaid coverage at higher income levels.

Medicaid Excess Income Program (Spenddown or Surplus Income Program)

SSI-related individuals (i.e., age 65 or older, blind or disabled) who are not eligible for Medicaid coverage because their income is higher than the Medicaid level for their residential situation must be given the opportunity to obtain coverage with a spenddown. To qualify, the individual’s medical expenses must be equal to or greater than the amount of their “excess income”. 

Excess income refers to the portion of countable total monthly income that is over and above the Medicaid level for the person’s living situation. To participate, the individual pays the amount of their excess income (or incurs expenses equal to or greater than the amount of their excess income), toward the cost of medical expenses each month. This effectively reduces income to the Medicaid level and Medicaid pays for remaining covered medical expenses during that month.

Medicaid uses a 6-month accounting period to compute an individual’s excess income. During this period, the person must be determined provisionally eligible for Medicaid. Coverage may be authorized for 1 to 6 months of this period. 

Upon notification that an excess income situation exists, the individual, their representative, or the individual’s care manager must develop a plan to ensure that the individual’s monthly spenddown requirement is met and that the LDSS is notified as early as possible in the month. It may be necessary to follow up with the LDSS to ensure that coverage is in effect. When the individual’s medical expenses do not meet or exceed the spenddown amount, the individual remains provisionally eligible for Medicaid, but coverage is not authorized and services are not paid.

Medical expenses that may be applied toward the spenddown include:

  • Any OPWDD or nonprofit agency-provided Medicaid billable service for which there is a rate or fee in place, e.g., care coordination, waiver, clinic and day treatment services (waiver services can only be used for spenddown purposes if the individual is enrolled in the HCBS Waiver)
  • Medical or dental expenses or payments made to physicians, therapists, nurses, personal care attendants, and home health aides (as required by a physician)
  • Reasonable transportation expenses to obtain necessary medical services
  • Prescription drug bills
  • Payments made toward surgical supplies, medical equipment, prosthetic devices, hearing aids, and eye glasses (as ordered by a doctor)
  • Expenses for chiropractic services (and other non-covered medical services)
  • Costs of some over-the-counter drugs and medical supplies such as bandages and dressings if ordered by a doctor and/or that are medically necessary

To avoid a spend down entirely, see the sections below on Medicaid Buy-In for Working People with Disabilities, DAC (Disabled Adult Child) budgeting or use a Supplemental Needs or Pooled Trust to eliminate or decrease the amount of income. 

Individuals have the choice of meeting the spenddown in one of two ways:

  • By incurring medical expenses equal to or greater than the excess income: An individual can become eligible for Medicaid for outpatient care and services in any month they have medical bills that equal or exceed the monthly spenddown amount if they submit those bills to the Medicaid district office. When a person submits paid or unpaid medical bills equal to or greater than the excess monthly income, they may receive Medicaid coverage for all other eligible outpatient services for that month. In this case, outpatient coverage is provided on a month-to-month basis.

    An individual can become eligible for full Medicaid coverage (inpatient and outpatient) for 6 months if they incur or pay medical bills equal to the total of 6 months of monthly excess income and present those bills to the Medicaid office.

    Medical expenses must be incurred to have them applied toward a spenddown. The individual may provide a combination of bills (paid or unpaid) to the Medicaid district to have the appropriate bills applied against their excess income. Expenses incurred for necessary medical and remedial services recognized under state law, whether covered by Medicaid or not, may be deducted from income.
  • By pre-paying excess income directly to the Medicaid district:  This is called the Pay-In Program and is akin to purchasing health insurance. To obtain coverage, the individual pre-pays their monthly excess income to the Medicaid district. The individual may elect to pre-pay for periods of 1 to 6 months. For pay-in periods of less than 6 months, outpatient coverage is authorized for a month only after the payment is made for the month. If the individual pays the total excess income for a 6-month period, full Medicaid coverage is provided for that period.

To establish an effective spenddown arrangement for an individual, the following should be considered:

  • If the individual has sufficient medical expenses that may be applied toward the spenddown and whether those services are provided by OPWDD, a nonprofit agency, and/or other provider 
  • To whom payment of the spenddown must be made (i.e., to one or more service providers, OPWDD, and/or the local Medicaid district)
  • Whether to fulfill the spenddown requirement by using the spenddown program or by participating in the Pay-In Program (see above).

Spenddown Examples can be found here: Examples of Calculations for Medicaid and SSI 

Medicaid Buy-In for Working People with Disabilities (MBI-WPD)

The MBI-WPD program is designed to encourage people with disabilities to start working, return to work, or earn more. It ensures that eligible working people with disabilities can keep or get Medicaid coverage for the services they need. When applying for Medicaid, working individuals will receive an explanation of the MBI-WPD program from their responsible LDSS. Individuals who have started working since their last renewal will receive an explanation of the MBI-WPD program at recertification. These notices will help them make an informed decision about participating in the MBI-WPD program. 
 
For FAQ, a tool kit and self-interview to see if a person is eligible, see Explanation of the Medicaid Buy-In Program for Working People with Disabilities at:
https://www.health.ny.gov/health_care/medicaid/program/buy_in/docs/working_people_with_disabilities.pdf

An individual may be eligible for the MBI-WPD program if they are:

  • between the ages of 16 and 65, and
  • working (and paying applicable taxes), and
  • do not reside in a Nursing Home, ICF/IID, Small Residential Unit or Developmental Center, and
  • meet the Social Security Administration’s definition of disabled. 

A disability determination may be required if one has not previously been completed. In addition to these eligibility requirements, an individual’s countable income and resources must be within the program limits.

Under the MBI-WPD program, individuals may have income up to 250% of the Federal Poverty Level. These amounts may change annually. Current income and asset information can be found at: http://www.health.ny.gov/health_care/medicaid/program/buy_in/.

Currently, the Department of Health is not collecting a premium for coverage through MBI-WPD. Eventually, they will start collecting a premium from MBI-WPD participants with countable income between 150% and 250% of the Federal Poverty Level (FPL). If an individual has countable income above 250% of the FPL, they are not eligible for MBI-WPD.

If an individual has health insurance coverage through their employer, they should discuss this with the LDSS or the local RSFO before applying for MBI-WPD coverage. Medicaid may cover the cost of the health insurance premium for the individual. If the person has family coverage, the individual should be aware that family coverage is not provided through MBI-WPD. Coverage for the individual’s spouse and children may be available through NYSOH, the New York state healthcare exchange at: https://nystateofhealth.ny.gov/.

All MBI-WPD participants are initially enrolled in the Basic Group. They may be moved to the Medicaid Improvement Group if they are medically improved. Most individuals served by OPWDD and its nonprofit providers will remain in the Basic Group due to the nature of their disabilities. If an individual is determined to be medically improved during a regular continuing disability review (CDR), they will receive notification from Medicaid. Participants in the Medical Improvement Group must meet additional program requirements, including working at least 40 hours per month and earning at least the Federal Minimum Wage.

Individuals uncertain about if they should apply for MBI-WPD instead of qualifying in the SSI-related category with a spenddown should contact their local Medicaid district or RSFO before applying. Individuals in receipt of SSI are not eligible for MBI-WPD because they already have full Medicaid coverage.

MBI-WPD Grace Period Requests

A person participating in MBI-WPD who stops working temporarily may be granted a grace period for continued participation in the program, depending on the reason they stop working. Grace periods may be granted if there is a change in the person’s medical condition making them temporarily unable to perform their job duties, or if they lost their job because of circumstances where they were not at fault (e.g., layoff, termination due to behavioral issues related to the person’s disability).

Individuals may be granted up to six months of grace period time in a 12-month period. The six-month limit may be comprised of multiple grace periods, provided the total grace period time does not exceed six months. During grace periods, the individual remains eligible for Medicaid coverage through MBI-WPD. If an individual does not return to work when the six-month limit has been reached, or if it is determined at some point during the grace period that the individual will not or cannot return to work at all, they are not eligible to continue to participate in MBI-WPD. To apply for a grace period, the individual or their Care Manager must submit a request to the applicable Medicaid district. Grace period request forms must be obtained from the local district. 

MBI – WPD Examples can be found here: Examples of Calculations for Medicaid and SSI 

Medicaid Extensions and Continuations

Certain individuals may be able to keep Medicaid coverage after losing eligibility for SSI. When a person’s SSI is terminated, Medicaid coverage continues until a separate Medicaid eligibility determination is made. This determination should be completed by the end of the calendar month following the month in which SSI was terminated. For any of these extension programs, the individual must continue to meet SSI disability and resource standards. 

Pickle Amendment

The Pickle Amendment allows an individual to continue to receive Medicaid if they lost SSI due to a Social Security Cost of Living Adjustment (COLA).

For continued Medicaid eligibility under the Pickle Amendment, the individual must meet the following criteria:

  • At any time after April 1977, the individual was entitled to both Supplemental Security Income (SSI) and Social Security Retirement, Survivors, or Disability (RSDI) benefits at the same time, and subsequently became ineligible for SSI because of Social Security cost of living adjustment; and
  • The individual is currently eligible for and receiving RSDI; and
  • The individual would be eligible for SSI if the Social Security RSDI COLAs received since the last month that they received both RSDI and SSI benefits were disregarded; and
  • The individual must live in an Individualized Residential Alternative (IRA), Community Residence (CR), Family Care home (FC), or at home.

If the person loses their Pickle budgeting eligibility due to resources over the SSI limit, their Pickle eligibility can be reinstated after they are under the SSI resource limit. This reinstatement has no time limit. If the person is found not to be disabled, they will lose their Pickle eligibility immediately. 

Pickle Budgeting Example can be found at: Insert link to Calculations Examples after uploading

If the person loses eligibility for Pickle budgeting due to their resources being over SSI limits, and they work, consider applying for the Medicaid Buy-In for Working People with Disabilities. If they do not work, review the resource management section of this toolkit. 

Pickle budgeting also allows for payment by New York State of the person’s Medicare Part B Premium, which can result in an increase of their monthly net income. As Pickle budgeted individuals are automatically eligible for this program as part of the “original buy-in” group, no application is necessary. If this is not automatically done, provide proof of the individual’s eligibility for the Pickle budgeting to the responsible Medicaid district and request they be added to the list of those for whom New York State will pay the Part B Medicare premium.    

Disabled Adult Child (DAC) Social Security Beneficiaries
 

Individuals who lose SSI benefits due to either the initial receipt of Social Security benefits on a parent’s work record or a subsequent increase in the Social Security benefits may be able to retain their Medicaid coverage.

To be eligible for Medicaid as a DAC, all the following must be true for the individual:

  • Be at least 18 years old
  • Have been eligible for SSI based on blindness or disability
  • Have become blind or disabled prior to age 22
  • Have lost SSI on or after July 1, 1987 due to an initial entitlement to or an increase in SSA Disabled Adult Child benefits
  • Continue to meet all other SSI eligibility requirements
  • Live in an Individualized Residential Alternative (IRA), Community Residence (CR), Family Care (FC) home, or at home

For a person who loses SSI eligibility due to the initial receipt of a DAC benefit or an increase in a DAC benefit, the DAC amount received the month before the month SSI eligibility ceased is used in determining the individual’s Medicaid eligibility. A person can be reinstated for special DAC budgeting (after having lost it for not meeting SSI resource eligibility) in any month in which the person again meets the SSI eligibility requirements. 

If the person loses eligibility for DAC budgeting due to their resources being over SSI limits, and they work, consider applying for the Medicaid Buy-In for Working People with Disabilities. If they do not work, review the resource management section of this toolkit. 

DAC budgeting also allows for payment by New York State of the person’s Medicare Part B Premium, which can result in an increase of their monthly net income. As DAC budgeted individuals are automatically eligible for this program as part of the “original buy-in” group, no application is necessary. If this is not automatically done, provide proof of the individual’s eligibility for the DAC budgeting to the responsible Medicaid district and request they be added to the list of those for whom New York State will pay the Part B Medicare premium.

DAC Budgeting Examples can be found here: Examples of Calculations for Medicaid and SSI 

Section 1619(b): Medicaid Coverage for Working Individuals Who Lose SSI

SSI recipients are often concerned that they will lose Medicaid if they go to work. Section 1619(b) of the Social Security Act provides some protection for these individuals by continuing Medicaid coverage if the individuals lost SSI payments because of earnings. To qualify for this continuing Medicaid coverage, a person must meet all the following criteria:

  • Have been eligible for an SSI cash payment for at least one month
  • Still meet the disability requirement
  • Still meet all other non-disability requirements for SSI
  • Need Medicaid benefits to work
  • Have gross earnings that are insufficient to replace SSI, Medicaid and publicly funded attendant care services

An SSI beneficiary who loses SSI cash payments because of high earnings may be eligible for Medicaid if they meet 1619(b) requirements. SSA uses a threshold amount to measure whether the individual’s earnings are high enough to replace their SSI and Medicaid benefits. The threshold amounts are updated annually and are published in the SSA Red Book. (https://www.ssa.gov/redbook/eng/main.htm). A person who loses 1619(b) eligibility due to high wages can request that SSA calculate an individualized threshold using the person’s actual medical expenses.

If a 1619(b) individual’s resources exceed the SSI resource level (currently $2,000) for a year or longer, the individual’s 1619(b) status is permanently terminated, and the Medicaid continuation ends. If an individual is no longer eligible under 1619(b) due to resources, the individual may apply for the MBI-WPD program. 

If the person no longer meets the disability requirement, the 1619(b) status is terminated immediately. In addition, if it becomes evident that Medicaid is no longer needed for the person to work, the 1619(b) status will end.
 
Individuals receiving Medicaid under 1619(b) status, like DAC and Pickle budgeting, are eligible for payment of the Medicare Part B premium by the State of New York. 

Receipt of Services

When Medicaid has been authorized, a recipient will receive a permanent plastic Client Benefit Identification Card (CBIC) that must be presented when receiving medical services from a Medicaid enrolled provider.

This card gives the provider the identifying information needed to verify the recipient’s eligibility on the date of service. The provider will also be able to determine if there is Medicare or other health insurance coverage that may be available to pay for the service. Since Medicaid is the payer of last resort, other sources of coverage must be used before the service is billed to Medicaid.

The card contains an individual’s ID #, commonly referred to as a CIN. This and the case number are personally identifying information and should only be released to those with a verified need for the HIPAA related information. 

Loss of Medicaid Card

To order a new Medicaid Client Benefit Identification Card, if the individual’s Medicaid is through the New York State of Health, contact the call center at (855) 355-5777. If the person’s Medicaid is through the local department of social services (LDSS) (https://www.health.ny.gov/health_care/medicaid/ldss.htm), call or visit that office. 

In New York City, call 311 to reach NYC HRA or call the HRA Medicaid Helpline at (888) 692-6116 to replace a Medicaid card. There is also an online request form: https://portal.311.nyc.gov/article/?kanumber=KA-02340.

When a new CBIC card is issued to an individual, any previously issued cards are invalidated.

Out of State Services

Medicaid coverage may be available for services needed outside New York State if the out-of-state provider is also a New York State Medicaid provider. Prior to traveling out of state, a Medicaid recipient or their representative should ask the medical providers they would like to use if the provider accepts New York State Medicaid. If the provider does not accept NYS Medicaid, but would like to, they can register at:
https://www.emedny.org/info/providerenrollment/

Transportation 

Requests for prior approval must be made with the NYS Department of Health (DOH) contracted transportation provider: 

This does not apply to programs or residences that have transportation included in their rate (e.g., IRA, CR, DC, ICF/IDD) unless it is emergency transportation or a physician orders special transportation – in those cases, prior approval must be obtained for Medicaid to pay the transportation claim.

Maintaining Eligibility

Recertification/Renewal

Medicaid coverage for a person not eligible as an SSI recipient must be recertified at least annually. Some individuals will be automatically recertified based on criteria set by the Department of Health. If not eligible for an automatic rectification, the individual or their authorized representative must complete a recertification form and provide all required documentation. 

Certain individuals are not required to provide documentation for Medicaid renewal. SSI-related recipients enrolled in the HCBS Waiver who are authorized for Community Coverage with Community Based Long-Term Care are not required to provide documentation of, but must attest to income, resources and residency changes at the time of Medicaid renewal.

A simplified Medicaid renewal form and mail-in process is available. The computer- generated Medicaid Renewal (Recertification) Form is mailed to the recipient and/or authorized representative with a cover letter to advise the individual that coverage is expiring. The letter explains the need to return the completed renewal form with current information and documentation, if required, to the appropriate LDSS. A paper version of the renewal is also in use.

Response to any Medicaid recertification request before the deadline on the form is imperative. Failure to do to so may result in termination of the person’s Medicaid coverage.

Reporting Changes to the Medicaid District

The individual or the individual’s authorized representative must notify the Medicaid district of changes that might affect Medicaid eligibility or coverage. The change must be reported within ten days after the end of the month in which the change occurred. The report must include the reporter's name, the name, CIN and case number of the individual, facts about the change and date of the change.

The following are examples of changes that the individual or representative must report:

  • Change of address
  • Change in living arrangement
  • Change in income
  • Change in resources
  • Change in other health insurance
  • Death of an individual
  • Death of a spouse or anyone in the individual’s household
  • Change in marital status
  • Change in citizenship or immigration status
  • Change in help with living expenses from friends or relatives
  • Admission to or discharge from, an institution (hospital, nursing home, prison or jail)
  • Absence from the state for more than 30 consecutive days
  • Medical improvement or other change of disabling condition 
  • Return to, loss of or retirement from work
  • Change in an IRWE
  • Change in an associated name
County-to-County Moves (Luberto)

When an individual moves from one county to another, the sending county (county from which the individual is moving) continues Medicaid coverage for a full month after the month it is notified by the Medicaid recipient of the move. The receiving county (county to which the individual is moving) opens Medicaid coverage based on the original county’s existing authorization period (usually 12 months). The receiving county keeps Medicaid coverage open until the person’s next scheduled Medicaid recertification or for a minimum of four months.

Medicaid recipients must notify their sending county in writing of their move and their new address for this policy to apply.  The policy does not apply to the following:

  • Supplemental Security Income recipients (there is an existing automated process to move coverage to the receiving county)
  • Individuals moving from a chronic care setting (e.g., ICF/IDD, hospital, psychiatric center, or nursing home)
  • Individuals being placed into a residence where OPWDD (District 98) or OMH (District 97) is the Medicaid district

Individuals in the latter two categories may have to reapply with the receiving district and should contact that district in writing for further information. 

Moves from NYSoH to Local District

Children who are OPWDD HCBS waiver recipients should have their Medicaid cases transitioned from the NYSoH to the local district. This will help prevent automatic terminations or changes to their case which also may affect their HCBS waiver services. Transitions can be made by contacting the NYS Department of Health Transition Team at [email protected], and providing the following information: 

  • Individual's Name
  • DOB
  • CIN
  • Account or case number
  • Type of waiver service(s) 
  • HCBS Waiver documentation

The HCBS Waiver documentation can be a notice of decision or letter of introduction from the RSFO or written notice from DDRO that the individual is an HCBS waiver applicant requesting specific services and has a completed HCBS waiver application on file pending Medicaid approval. 

Medicaid Denial, Case Closing, or Reduction of Benefits

If an individual does not agree with the denial of their application, termination of coverage, or reduction in benefits, they have the right to appeal the determination. The applicant may request a local conference, a fair hearing or both.

The purpose of a local conference is to review information provided, discuss the basis for the decision, answer questions and seek to resolve any misunderstandings. If the worker determines that an incorrect decision was made, a corrected notice is prepared and given to the applicant and necessary action is taken to activate or correct the individual’s Medicaid coverage.

If a fair hearing is needed, the request must be filed within 60 days of the notice date on the Notice of Decision. If the request is not received by DOH by the deadline, DOH may choose not to hear the complaint. If a request for a fair hearing is filed before the Notice of Decision takes effect (within 10 days), Medicaid coverage, if already in place, must be continued unchanged until the fair hearing decision is issued.

Requesting a Fair Hearing

Individuals can ask for a fair hearing by:

  • Calling the statewide toll-free number: (800) 342-3334
  • Faxing: (518) 473-6735
  • Online at: https://otda.ny.gov/hearings/request/#online
  • Writing to: The Fair Hearing Section, New York State Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York 12201

Medicaid Managed Care

Managed care is a health care system that coordinates the provision, quality and cost of care for its enrolled members. When an individual joins a managed care plan, the individual selects a doctor, often referred to as a primary care practitioner (PCP), who is responsible for coordinating their health care.

Medicaid Managed Care (MMC) offers many New Yorkers a chance to choose a Medicaid health plan that focuses on preventative health care. In most counties, if an individual is eligible for Medicaid, they are required to join a managed care health plan. There are some exceptions to mandatory enrollment (see Enrollment in Medicaid Managed Care below). Enrollment in an MMC program through a Health Maintenance Organization (HMO), clinic, hospital, or physician group is available at most LDSS offices. After joining a managed care plan, individuals must use participating providers (physicians, therapists, etc.) to access health services.

Services Covered Under Medicaid Managed Care

Medicaid Managed Care (MMC) covers most of the benefits an individual will need, including all preventative and primary care, inpatient care, and eye care. Individuals with managed care plans can use their Medicaid benefit card to access services that the plan does not cover (carved-out services).

Note: Individuals enrolled in MMC can receive CCO and be enrolled in the HCBS Waiver.

Enrollment in Medicaid Managed Care

Enrollment in MMC is required unless an individual meets the criteria for either exempt or excluded categories. Exempt individuals can choose if they want to enroll in MMC. Excluded individuals are not allowed to enroll in MMC and if they are already enrolled, they must be disenrolled.

The following individuals are currently exempt:

  • Individuals enrolled in the OPWDD HCBS Waiver
  • Individuals enrolled in a Children’s Waiver
  • Individuals enrolled in a TBI Waiver
  • Individuals with characteristics and needs similar to individuals enrolled in a Children’s Waiver, HCBS Waiver, or those living in ICFs or DCs (commonly referred to as “look- alikes”)
  • Native Americans

Individuals residing in ICF/IIDs, DCs and SRUs, those receiving both Medicaid and Medicare (dual eligibles) and individuals with comprehensive Third Party Health Insurance are currently excluded from MMC.

SSI beneficiaries must choose a plan within 90 days of receiving the mailing regarding Medicaid Managed Care. Individuals who do not choose a health plan within this timeframe will be automatically assigned to a health plan. New York State has contracted with an enrollment broker to assist individuals with selecting a managed care plan. New York Medicaid Choice (NYMC), also called Maximus, can be reached at: 1-800-505-5678 or https://www.nymedicaidchoice.com/ 

Additional information regarding Medicaid Managed Care can be found at: http://www.health.ny.gov/health_care/managed_care/index.htm.

OPWDD & Medicaid Managed Care

As of 2021, OPWDD expects to partner with several managed care plans serving people with developmental disabilities and their families. The initial enrollment into these plans will be voluntary, but eventually the exemptions above will be lifted. After a year, OPWDD expects that those not excluded from Medicaid managed care (see above) will be enrolled into managed care.  

FIDA (Fully Integrated Dual Advantage Plan)

OPWDD currently works with Partners Health Plan (PHP) to provide Medicaid managed care to people with developmental disabilities in the downstate area. All Medicaid and Medicare services are covered by Partners Health Plan (PHP) including comprehensive care coordination, HCBS waiver services, doctors, medication, transportation and dental. There are no deductibles, premiums, copays or coinsurance for this plan. To be eligible for the FIDA, a person must:

  • Be over age 21, and
  • Live in NYC, Nassau, Rockland, Suffolk or Westchester, and 
  • Have both Medicaid and Medicare (dual eligible), and 
  • Receive Medicaid through LDSS or OPWDD District 98, not NYSoH, and
  • Be OPWDD and ICF Level of Care eligible, and
  • Not reside in a nursing home, DC/SRU, OASAS or OMH facility.

Enrollment in the program is voluntary. NY Medicaid Choice (NYMC) has a dedicated phone number for the FIDA-IDD at (844) 343-2433. NYMC will also send letters inviting people to enroll and will forward the enrollment packet needed to join the plan. Enrollment is also always prospective. For example, if the person requests enrollment on January 5, the enrollment will be effective February 1. Enrollment must be completed before the 20th of any given month.   

If an individual must or chooses to dis-enroll from the FIDA-IDD, PHP is responsible for coordinating the transition of the services and helping the individual find a care manager if the plan is informed in a timely manner. While PHP will not enroll individuals into the FIDA while they reside in a nursing home, they will pay for short term nursing home costs, if a person living at home and already enrolled in the FIDA needs that care. 

FIDA-IDD is the only MLTC plan that OPWDD HCBS Waiver enrollees can join.

Further information about this unique program is available at: https://opwdd.ny.gov/location/partners-health-planfida-idd.  

Managed Long-Term Care

Managed Long-Term Care (MLTC) plans are different from MMC and it is important that individuals and providers understand the differences. While MMC plans, as described above, will pay for OPWDD services or allow fee-for-service payment for these services, MLTC plans will not pay for any OPWDD services. Individuals wanting to enroll in a MLTC plan must choose between OPWDD services and the services covered by the MLTC plan as they cannot be enrolled in both at the same time. The only exception to this is the FIDA-IDD plan seen above.

To determine if an individual is enrolled in Managed Long Term Care or Mainstream Managed Care, look at the plan code in ePACES and compare to the chart on the DOH website at:
https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers_Managed_Care_Information.pdf.  

PACE (Program of All-Inclusive Care for the Elderly)

The Programs of All-Inclusive Care for the Elderly (PACE) is a type of MLTC. People can’t be enrolled in both PACE and the OPWDD HCBS Waiver. Information about PACE is available at:

https://www.medicaid.gov/medicaid/long-term-services-supports/program-all-inclusive-care-elderly/index.html

https://www.medicaid.gov/medicaid/long-term-services-supports/pace/programs-all-inclusive-care-elderly-benefits/index.html

https://www.nymedicaidchoice.com/ask/pace

 

New York State Managed Care Plan Types and Authorities

Plans Serving Medicaid/Medicare Eligible Individuals
  Medicaid Advantage Plus1 PACE1 FIDA1 FIDA-IDD Medicaid Advantage Partial MLTC
Mandatory/
Voluntary
Voluntary Voluntary Voluntary
(passive enrollment)
Voluntary Voluntary Mandatory
Eligibility
Age
Require LTSS for 120 days.
NH or ICF level or care.

18 or older

Yes

Yes

55 years+, eligible for Medicare and/or Medicaid or private pay

Yes

Yes

21 or older

Yes

Yes

21 or older

Yes

Yes

18 or older

Yes

Yes

18 or older

Yes

Yes

IDD Eligibility4 May enroll, cannot enroll in HCBS Waiver May enroll, cannot enroll in HCBS Waiver May enroll, cannot enroll in HCBS Waiver May enroll, can enroll in HCBS Waiver May enroll, cannot enroll in HCBS Waiver May enroll, cannot enroll in HCBS Waiver
Coverage Area(s) 4 Capital Region Counties, LI, Rockland, Westchester 6 WNY counties, NYC, Albany, Onondaga, Schenectady, Suffolk, Westchester NYC, LI, Westchester NYC, LI, Rockland, Westchester Statewide  Statewide (Phase-in)
Benefits3 Comprehensive Medical, Long Term Supports & Services Comprehensive Medical, Long Term Supports & Services Comprehensive Medical, Long Term Supports & Services and certain Behavioral Health Services Comprehensive Medical, Long Term Supports & Services, OPWDD services and certain Behavioral Health Services Comprehensive Medical, Co-payment and Co-insurance and Medicaid wrap for non-Medicare covered services Medicaid Long Term Supports & Services

 

Plans Serving Medicaid Eligible Individuals Only

 

Mainstream Managed Care HARP2 HIV SNP2

Mandatory/
Voluntary

Mandatory Voluntary Voluntary
Eligibility
Age
Require LTSS for 120 days.
NH or ICF level or care.

Any age if not otherwise excluded from enrollment

No 

No

21 or older

No

No

HIV positive must
Birth to 64 years

No

No

IDD Eligibility4 May enroll, can enroll in HCBS Waiver May enroll, cannot enroll in HCBS Waiver May enroll, can enroll in HCBS Waiver
Coverage Area(s) Statewide (Phase-in) Statewide (Phase-in) NYC
Benefits3 Comprehensive Medicaid Benefits Comprehensive Medicaid Benefits plus Health Home and Behavioral Health Benefits Comprehensive Medicaid Benefits and enhanced HIV services, Health Home and Behavioral Health Benefits if qualify

 1 – An individual, to receive LTSS, is mandated to enroll in a Managed Long Term Care Plan. Dual Individuals enrolled in a partial cap are passively enrolled into the FIDA.  
2 – HARP & HIV SNP are Medicaid-only alternative plan options for qualified individuals, who otherwise are mandatorily enrolled into Mainstream Managed Care.
3 – “Comprehensive” refers to a medical benefit package that includes acute inpatient and outpatient services, pharmacy, LTSS and care management.
4 – Individuals with IDD eligibility must also meet the standard eligibility requirements indicated above under each Managed Care Plan type.

Child Health Plus

Child Health Plus (CHPlus) is New York State’s free or low-cost health insurance for children up to age 19 who are not eligible for Medicaid. Children enrolled receive care through managed care plans. Under CHPlus, there is no fee-for-service component and OPWDD services are not covered. Information regarding CHPlus is included here because it may be useful for family members of individuals served by OPWDD.

Depending on the family's income, a child not eligible for Medicaid may qualify for Child Health Plus. Information about this program can be obtained by calling 1-800-698- 4KIDS (1-800-698-4543) and asking about Child Health Plus. Information, including income and coverage charts, can also be found at the New York State Department of Health’s website at: 

https://www.health.ny.gov/health_care/child_health_plus/eligibility_and_cost.htm 

https://www.health.ny.gov/health_care/child_health_plus/what_benefits_can_you_get.htm

Application Process

Applying for Child Health Plus is done through the New York State of Health (NYSOH) website at https://nystateofhealth.ny.gov/. To determine what coverage a person will receive and if help to pay for coverage is available, the following information may be requested:

Social Security numbers (or document numbers for legal immigrants who need health insurance)

  • Birth dates
  • Employer and income information for everyone in the family
  • Policy numbers for any current health insurance
  • Information about any job-related health insurance available to the family

Assistance with the application process is available through In-Person Assistors (IPAs), Navigators and Certified Application Counselors (CACs), all of which are trained and certified by the New York State Department of Health.

IPAs/Navigators provide in-person enrollment assistance to people who would like help applying for health insurance through the Marketplace. Assistance is provided in convenient, community-based locations and is free. A list of IPA/Navigator Site locations can be found at: http://info.nystateofhealth.ny.gov/IPANavigatorSiteLocations.

CACs are also trained to provide enrollment assistance to individuals applying for coverage through the Marketplace, and may work in places like hospitals, clinics, providers and health plans. More information about CACs, including where they are located, can be obtained by calling 1-855-355-5777.

Conversion Process

Should a child with Child Health Plus coverage need OPWDD services, bring their case to the attention of the NYS Department of Health transition unit (see above). They will assist in moving the case from CHP to the county LDSS for Medicaid coverage.