Eligibility

Learn about eligibility criteria for Medicaid, including income levels and what documents are required to apply.

Q. How do I know if I qualify for Medicaid?

A. You may qualify for Medicaid depending on your age, financial circumstances, family situation, or living arrangement. Use the link below to see which health insurance options are available to you, including if your income qualifies you for NYS Medicaid.

• NY State of Health, the Official Health Plan Marketplace

If you qualify under a MAGI eligibility group, you will have to provide documents
              to verify eligibility if necessary.

• If you are applying for Medicaid through the Marketplace (NY State of Health), you may attest to your household income for the upcoming year. If your income is different than the income found on the data matches, income documentation may need to be provided.
• Citizenship/Immigration status and social security number will be verified through federal data sources. If citizenship/immigration status or social security number does not match, documentation must be provided.

If you qualify under a non-MAGI eligibility group, the following is a guide to the
              documentation that must be submitted to help determine eligibility

• If you are a U.S. citizen (born in the U.S. or one of its territories) and provide a valid Social Security Number (SSN), a match with the Social Security Administration (SSA) will verify your SSN, date of birth and U.S. citizenship. If SSA verifies this information, no further proof is needed. The SSA match cannot verify birth information for a naturalized citizen. You will need to submit proof of naturalization (e.g., Naturalization Certificate (N-550 or N-570) or a U.S. passport.
• Proof of citizenship or immigration status*
• Proof of age (if not verified by SSA), like a birth certificate
• Four weeks of recent paycheck stubs (if you are working)
• Proof of your income from sources like Social Security, Veteran's Benefits (VA), retirement benefits, Unemployment Insurance Benefits (UIB), Child Support payments
• If you are age 65 or older, or certified blind or disabled, and applying for nursing home care waivered services, or other community based long term care services, you need to provide information on bank accounts, insurance policies and other resources
• Proof of where you live, such as a rent receipt, landlord statement, mortgage statement, or envelope from mail you received recently
• Insurance benefit card or the policy (if you have any other health insurance)
• Medicare Benefit Card (the red, white, and blue card)**

• *Note: Medicaid coverage is available, regardless of alien status, if you are pregnant or require treatment for an emergency medical condition and you meet all other Medicaid eligibility requirements.
• **Note: As a condition of eligibility for Medicaid, if you appear eligible for Medicare, you must apply and show proof of application.
  You are required to apply for Medicare if:
  • You have Chronic Renal Failure or Amyotrophic Lateral Sclerosis (ALS); OR
  • You are turning age 65 in the next three months or are already age 65 or older; AND your income is below 120% of the Federal Poverty Level (based on the household size for a single individual or married couple), or is at or below the applicable Medicaid Standard, then the Medicaid program will pay or reimburse you the cost of your Medicare premiums. If the Medicaid program can pay your premiums, you will be required to apply for Medicare as a condition of Medicaid eligibility.

  Proof of Medicare application can be:

  • Your award or denial letter from the Social Security Administration, OR
  • Your on-line confirmation letter stating that you have applied for Medicare with the Social Security Administration.

  Apply Now:

  • https://www.ssa.gov/medicare/
  • https://www.medicare.gov/people-like-me/new-to-medicare/getting-started-with-medicare.html
  • Social Security Administration 1-800-772-1213

Q. If I think I am eligible for Medicaid, should I cancel any other health insurance I might already have?

A. No. If you currently pay for health insurance or Medicare coverage or have the option of getting that coverage, but cannot afford the payment, Medicaid can pay the premiums under certain circumstances.

Even if you are not eligible for Medicaid benefits, the premiums can still be paid, in some instances, if you lose your job or have your work hours reduced. If you need help with a COBRA premium, you must apply quickly, to determine if Medicaid can help pay the premium.

You may be eligible for the Medicare Savings Program. This program pays your Medicare premiums and for some consumers, can also pay your Medicare deductibles, coinsurance, and copayments.

If you have Acquired Immune Deficiency Syndrome (AIDS), Medicaid may be able to help pay your health insurance premiums.

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Q. How do I know if my income and resources qualify me for Medicaid?

A. The chart below shows how much income you can receive in a month and the amount of resources (if applicable) you can retain and still qualify for Medicaid. The income and resource (if applicable) levels depend on the number of your family members who live with you.

Family Size	Net Income for Families and Individuals who are Blind, Disabled or Age 65+		Resource Level (Individuals who are Blind, Disabled or Age 65+ ONLY)
	Annual	Monthly
1	$20,121	$1,677	$30,182
2	$27,214	$2,268	$40,821
3	$34,307	$2,859
4	$41,400	$3,450
5	$48,494	$4,042
6	$55,587	$4,633
7	$62,680	$5,224
8	$69,773	$5,815
9	$76,866	$6,406
10	$83,960	$6,997
For each additional person, add:	$7,094	$592

Effective January 1, 2023. Income and Resource Levels are subject to yearly adjustments.

You may also own a home, a car, and personal property and still be eligible. The income and resources (if applicable) of legally responsible relatives in the household will also be counted.

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Expanded Income levels for Children and Pregnant Individuals

• Infants to age one and pregnant individuals - 223% of the federal poverty level.
• Children age 1 through 18 years - 154% of the federal poverty level.

Monthly Income Effective January 1, 2022*
Number in Family	154% FPL**	223% FPL**
1	$1,745	$2,526
2	$2,350	$3,403
3	$2,956	$4,280
4	$3,562	$5,157
5	$4,167	$6,035
6	$4,773	$6,912
7	$5,379	$7,789
8	$5,985	$8,666
For each additional person, add:	$606	$878

• * Income Levels are subject to yearly adjustments.
• ** FPL = Federal Poverty Level

If a child has too much income and is not eligible for Medicaid, the child may be eligible for Child Health Plus.

Q. If my income is in a Trust, does that impact my Medicaid eligibility?

A. For more information on Trusts, please visit our Trust-Specific information page.

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Q. Can I be eligible for Medicaid even if I make more money than the chart shows?

A. Yes, some people can. If you are under 21 years of age, over 65 years of age, certified blind, certified disabled, pregnant, or a parent of a child under 21 years of age, you may be eligible for Medicaid if your income is above these levels and have medical bills. For more information please visit the Medicaid Excess Income Program webpage.

People who are certified blind, certified disabled, or age 65 or older who have more resources may also be eligible.

If an adult has too much income and/or resources and is not eligible for Medicaid, they may be eligible for the Family Planning Benefit Program.

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Q. Will there be a lien (legal claim) placed on my estate (my assets) when I die?

If you receive medical services paid for by Medicaid on or after your 55th birthday, or when permanently residing in a medical institution, Medicaid may recover the amount of the cost of these services from the assets in your estate upon your death.

For individuals who received Medicaid under a MAGI eligibility group, the estate recovery is limited to the amount Medicaid paid for the cost of nursing facility services, home and community-based services, and related hospital and prescription drug services received on or after the individual's 55th birthday.

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How Do I Request an Assessment of My and My Spouse's Resources for Spousal Impoverishment?

Either spouse, or a representative acting on their behalf, may request an assessment of the couple's countable resources at the beginning or any time after the beginning of a continuous period of institutionalization. The DOH-5298, "Request for Assessment– Spousal Impoverishment" form is used to request an assessment. Upon receipt of such request and all relevant documentation, the local district will assess the total value of the couple's countable resources and provide each spouse with a copy of the assessment and the documentation upon which it is based. If the request is not filed with a NYS Medicaid application, the local department of social services may charge up to $25.00 for the cost of preparing and copying the assessment and documentation.

If you wish to request an assessment of the total value of your and your spouse's countable resources, a determination of the community spouse resource allowance, community spouse monthly income allowance, or family member allowance(s) and the method of computing such allowances, please contact your local department of social services. NYC residents should call the HRA Medicaid Helpline at (888) 692-6116.

Children and Pregnant Individuals

Learn about Medicaid eligibility for children and pregnant individuals.

Q. What are the Medicaid eligible income levels for children and pregnant individuals?

A. Income levels in relation to the federal pverty level are as follows:

• Infants to up to one year of age and pregnant individuals = 223% of the federal poverty level.
Children one year of age through 18 years of age = 154% of the federal poverty level.

Monthly Income Effective January 1, 2022*
Number in Family	154% FPL**	223% FPL**
1	$1,745	$2,526
2	$2,350	$3,403
3	$2,956	$4,280
4	$3,562	$5,157
5	$4,167	$6,035
6	$4,773	$6,912
7	$5,379	$7,789
8	$5,985	$8,666
For each additional person, add:	$606	$878

• * Income Levels are subject to yearly adjustments.
• ** FPL = Federal Poverty Level

If a child has too much income and is not eligible for Medicaid, the child may be eligible for Child Health Plus.

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Q. Where do I find more information about Child Health Plus.

A.Additional information on Child Health Plus, including how to apply, can be found at: www.health.ny.gov/health_care/child_health_plus/.

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Applicants who are Blind, Disabled, and/or Over 65 Years of Age

Learn about specific circumstances for certain categories of applicants.

Q. What are resources?

A.Resources are cash or those assets, which can be readily converted to cash, such as bank accounts, life insurance policies, stocks, bonds, mutual fund shares and promissory notes. Resources also include property not readily converted to cash (i.e., real property)

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Q. Can I still keep part of my income if I am in a Residential Health Care Facility or in an intermediate care facility for the developmentally disabled?

A.Yes. Under Medicaid you are allowed to keep a small amount for your personal needs. You can also keep some of your income for your family if they are dependent on you. A spouse who remains in the community may also keep resources and income above the levels shown.

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Q. What is a "lookback" period?

A. When applying for Medicaid for nursing facility services (Nursing Home), the local department of social services will look at financial transactions to determine whether any assets have been transferred or given away for less than fair market value during a certain time period prior to your application in order to determine if a transfer of assets penalty period needs to be applied. This is known as the "lookback" period. Currently the "lookback" period is 60 months (5 yrs) prior to the month you are applying for coverage of nursing home care.

A penalty period may be imposed for the transfer of non-exempt assets for less than fair market value. The penalty period results in a period of ineligibility for Medicaid coverage of nursing facility services.

A penalty period is not applied for the transfer of your home to the following individuals:

• Spouse
• Child under the age of 21
• Sibling who has an equity interest in the home and has resided in the home for at least one year immediately prior to you entering the Nursing Home.
• Adult child who resided in the home for at least two years, immediately prior to you entering the Nursing Home and who provided care to you which permitted you to reside at home rather than in a medical facility.

For more information regarding the transfer of assets and penalty periods, please contact your local department of social services.

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Q. What is a Life Estate? Will it make me ineligible?

A. A life estate is limited interest in real property. A life estate holder does not have full title to the property, but has the use of the property for his or her lifetime, or for a specified period. The life estate is not considered a countable resource, and no lien may be placed on it.

If you or your spouse sell the life estate interest for less than fair market value, it can be considered a transfer of assets and may be subject to the penalty period.

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Q. Am I allowed to have a pre-paid burial fund?

A. You may establish an irrevocable pre-need funeral agreement with a funeral firm, funeral director, undertaker or any other person, firm or corporation which can create such an agreement for your funeral and burial expenses. Pre-need burial agreements purchased for certain members of your family on or after January 1, 2011 must also be irrevocable. The pre-need funeral agreement is used towards burial and funeral expenses and is not counted as a resource when determining Medicaid eligibility.

If you (your spouse) do not have an irrevocable pre-need funeral agreement or if the irrevocable pre-need agreement has less than $1500 designated for non-burial space items, you may be allowed to have money set aside in a burial fund. The limit for single individuals is $1500 or $3000 for a couple. Please note, these funds, must be kept separate from any non- burial fund related resources.

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Q. If I have an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), can I get my eligibility for these services processed more quickly?

A. Immediate Need for PCS/CDPAS: Informational Notice and Attestation Form (DOH-5786).

If you think you have an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), you may have your eligibility for these services processed more quickly if you:

• have no voluntary informal caregivers able and willing to provide or continue to provide care;
• are not receiving needed assistance from a home care services agency;
• have no third party insurance or Medicare benefits available to pay for needed assistance; and
• have no adaptive or specialized equipment or supplies in use to meet, or that cannot meet, your need for assistance.

If you don't have Medicaid coverage, you may ask to have your Medicaid application processed more quickly by sending in: a completed Access NY Health Insurance Application (DOH-4220); an **Access NY Supplement A (DOH-5178A), if needed; a physician's order (DOH-4359 or HCSP-M11Q or Practitioner Statement of Need (DOH-5779) for services; and a signed Attestation of Immediate Need (DOH-5786) to your local department of social services.

If you already have Medicaid coverage that does not include coverage for community-based long term care services, you must send in an **Access NY Supplement A (DOH-5178A), if needed; a physician's order (DOH-4359 or HCSP-M11Q or Practitioner Statement of Need (DOH-5779) for services; and a signed Attestation of Immediate Need (DOH-5786) to your local department of social services.

If you already have Medicaid coverage that includes coverage for community-based long term care services, you must send in a physician's order (DOH-4359 or HCSP-M11Q or Practitioner Statement of Need (DOH-5779) for services and a signed Attestation of Immediate Need (DOH-5786) to your local department of social services.

If you don't already have Medicaid coverage or you have Medicaid coverage that does not include coverage for community-based long term care services: All of the required forms (see the appropriate list, above) must be sent in to your local social services office or, if you live in NYC, to the Human Resources Administration (HRA). As soon as possible after receiving all of these forms, the social services office/HRA will then check to make sure that you have sent in all the information necessary to determine your Medicaid eligibility. If more information is needed, they must send you a letter, by no later than four days after receiving these required forms, to request the missing information. This letter will tell you what documents or information you need to send in and the date by which you must send it. By no later than 7 days after the social service office/HRA receives the necessary information, they must let you know if you are eligible for Medicaid. By no later than 12 days after receiving all the necessary information, the social services office/HRA will also determine whether you could get PCS or CDPAS if you are found eligible for Medicaid. You cannot get this home care from Medicaid unless you are found eligible for Medicaid. If you are found eligible for Medicaid and PCS or CDPAS, the social services office/HRA will let you know and you will get the home care as quickly as possible.

If you already have Medicaid coverage that includes coverage for community-based long term care services: The physician's order (DOH-4359 or HCSP-M11Q or Practitioner Statement of Need (DOH-5779) and the signed Attestation of Immediate Need (DOH-5786) must be sent to your local social services office or HRA. By no later than 12 days after receiving these required forms, the social services office/HRA will determine whether you can get PCS or CDPAS. If you are found eligible for PCS or CDPAS, the social services office/HRA will let you know and you will get the home care as quickly as possible.

**Note: Individuals with an immediate need for Personal Care Services or Consumer Directed Personal Assistance Services may attest to the current value of any real property and to the current dollar amount of any bank accounts.

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