medicaid-logoYou probably have heard of Medicaid, and how it helps people get the health care they need. You might not know, though, what exactly it is, what it offers, and if you are eligible. Here are a few important facts about Medicaid that can help you find out if it’s right for you and your family.

What is Medicaid?

Medicaid is a program for New Yorkers who can’t afford to pay for medical care.

How do I know if I qualify for Medicaid?

You may be covered by Medicaid if:

  • You have high medical bills.
  • You receive Supplemental Security Income (SSI).
  • You meet certain financial requirements.

How do I apply for Medicaid?

Applications may be completed online, in person with a navigator or certified application counselor, by mail and by phone. Call the Perinatal Network to schedule an appointment to apply for Medicaid at 315-732-4657 or toll free 877-267-6193

What health services are covered by Medicaid?

In general, the following services are paid for by Medicaid, but some may not be covered for you because of your age, financial circumstances, family situation, transfer of resource requirements, or living arrangements. Some services have small co-payments. These services may be provided using your Medicaid card or through your managed care plan if you are enrolled in managed care. You will not have a co-pay if you are in a managed care plan, except for pharmacy services, where a small co-pay will be applied.

  • smoking cessation agents
  • treatment and preventive health and dental care (doctors and dentists)
  • hospital inpatient and outpatient services
  • laboratory and X-ray services
  • care in a nursing home
  • care through home health agencies and personal care
  • treatment in psychiatric hospitals (for persons under 21 or those 65 and older), mental health facilities, and facilities for the mentally retarded or the developmentally disabled
  • family planning services
  • early periodic screening, diagnosis, and treatment for children under 21 years of age under the Child/Teen Health Program
  • medicine, supplies, medical equipment, and appliances (wheelchairs, etc.)
  • clinic services
  • transportation to medical appointments, including public transportation and car mileage
  • emergency ambulance transportation to a hospital
  • prenatal care
  • some insurance and Medicare premiums
  • other health services

If you are eligible for Medicaid, you will receive a Benefit Identification Card which must be used when you need medical services. There may be limitations on certain services.

For you to use your Benefit Identification Card for certain medical supplies, equipment, or services (e.g., wheelchair, orthopedic shoes, transportation), you or the person or facility that will provide the service must receive approval before the service can be provided (prior approval).

Will I have to pay co-payments?

The following services are subject to a co-payment:

  • Clinic Visits (Hospital-Based and Free Standing Article 28 Health Department-certified facilities) – $3.00;
  • Laboratory Tests performed by an independent clinical laboratory or any hospital-based/free standing clinic laboratory – $0.50 per procedure;
  • Medical Supplies including syringes, bandages, gloves, sterile irrigation solutions, incontinence pads, ostomy bags, heating pads, hearing aid batteries, nutritional supplements, etc. – $1.00 per claim;
  • Inpatient Hospital Stays (involving at least one overnight stay; is due upon discharge) – $25.00;
  • Emergency Room – for non-urgent or non-emergency services – $3.00 per visit;
  • Pharmacy Prescription Drugs – $3.00 Brand Name Non-Preferred, $1.00 Brand Name Preferred, $1.00 Brand When Less Than Generic, $1.00 Generic;
  • Non-Prescription (over the counter) Drugs – $0.50.

There is no co-payment on private practicing physician services (including laboratory and/or x-ray services, home health services, personal care services or long term home health care services).

Co-pay Maximum

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

Co-pay Exemptions

The following are exempt from all Medicaid co-payments:

  • Children under 21.
  • Pregnant women. (Pregnant women are exempt during pregnancy and for the two months after the month in which the pregnancy ends.)
  • Family planning (birth control) services -This includes family planning drugs or supplies like birth control pills and condoms.
  • Residents of an Adult Care Facility licensed by the New York State Department of Health.
  • Residents of a Nursing Home.
  • Residents of an Office of Mental Health (OMH) or Office for People with Developmental Disabilities (OPWDD) certified Community Residence.
  • Enrollees in a Comprehensive Medical Case Management (CMCM) or Services Coordination Program.
  • Enrollees in the Home and Community Based Services (HCBS) or Traumatic Brain Injury (TBI) waiver programs.
  • Psychotropic and Tuberculosis drugs.

You cannot be denied care or services because of your inability to pay a co-payment. A provider has the right to ask you for the co-payment at each visit and bill you for any unpaid co-payments.

Call the Perinatal Network to schedule an appointment to apply for Medicaid at 315-732-4657 or toll free 877-267-6193

Contact Us

Mohawk Valley Perinatal Network
3 Parkside Court, Building 2
Utica, NY 13501

Phone: 315-732-4657
Toll Free: 1-877-267-6193
Fax: 315-732-5640


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