There are several categorically-eligible groups including individuals receiving public assistance and individuals receiving SSI.

To be eligible for Medicaid in New York, recipients must be a New York State resident, have adequate immigration status, and be below the income limit.

Citizens, qualified aliens (e.g. lawful permanent residents, refugees, and asylees), Permanently Residing Under Color of Law (e.g., DACA, temporary nonimmigrants), and pregnant individuals are eligible for Medicaid. Individuals who are out of status (unless pregnant) are not eligible for Medicaid but may receive Medicaid for treatment of an emergency condition. Beginning January 1, 2024, individuals who are 65+ will be eligible for full Medicaid even if they are out of status.

Medicaid has two basic eligibility categories: Modified Adjusted Gross Income (MAGI) and non-MAGI. Children, childless adults ages 19 to 64 without Medicare, pregnant women, parents, caretaker relatives, and certified disabled individuals without Medicare are budgeted through the MAGI category. Adults over 65, Medicare recipients, recipients of TANF, SSI, foster care, and individuals with a disability determination are budgeted through non-MAGI. The two eligibility categories have the same income limits but there are some differences in the way that income is calculated, MAGI does not have a resource test.

A current breakdown of New York State’s income and resource limits can be found on the New York State of Health Website.

Individuals eligible for Medicaid through the MAGI category can apply to Medicaid through the New York State of Health. This can be done online or over the phone at 855-355-5777.

For individuals in the non-MAGI category, Medicaid is administered through the New York City Human Resources Administration (or for those outside of New York City, by the county’s Local Department of Social Services). Individuals eligible for Medicaid through the non-MAGI category can apply through their local Medicaid office. You can find out more information about applying through the Medicaid Helpline at 888-692-6116. You can also reach out to an organization in this list of facilitated enrollers for assistance.

Medicaid coverage for all categories can be retroactive for up to three months if the applicant was eligible during that time period.

Can I appeal if services were denied, reduced or discontinued?

Medicaid Eligibility

If you received a decision about your Medicaid eligibility, you have the right to request a Fair Hearing with the Office of Temporary and Disability Assistance (“OTDA”) within 60 days of the notice to challenge the denial or discontinuance. If it is a discontinuance or reduction of Medicaid eligibility, you must request a Fair Hearing within 10 days for services to remain unchanged.

Medicaid Managed Care

If you have a Medicaid Managed Care plan, you must first file an appeal with your plan called a Plan Appeal. You have 60 days to request a plan appeal. If the need is urgent, you may request that the appeal be fast-tracked. If your Plan Appeal is denied, you have a right to request a Fair Hearing with OTDA to challenge the denial within 120 days.

If you received a reduction or discontinuance of services, you must request the Plan Appeal within 10 days of the notice date or before the effective date to continue services unchanged. You then must request a Fair Hearing within 10 days of the Final Adverse Determination to continue services unchanged. NOTE: currently, during the winddown of COVID Medicaid protections, aid continuing is provided even if the hearing is not requested within 10 days.

Fee-for-service Medicaid

If you have fee-for-service Medicaid, or if you are challenging the denial of a service that is provided through fee-for-service (like prescription drugs), you have a right to request a Fair Hearing with OTDA to challenge the decision within 60 days of the notice.

If your Medicaid services were denied, reduced, or discontinued without notice, you can request a Fair Hearing. If you received a reduction or discontinuance without notice, you can ask for aid continuing and your services will remain unchanged until a decision is issued.

You can request a Fair Hearing over the phone at 800-342-3334. You can also request a Fair Hearing online.

You will then receive a notice telling you the time and location of your hearing.

Note: there is more information about the Fair Hearing process here (this site focuses on Fair Hearings on other benefits besides Medicaid, but still has helpful information about the Fair Hearing process).

Yes. You are not required to have representation at a Fair Hearing, but if you want representation at a Fair Hearing you can call the Access to Benefits Helpline from Monday through Friday, 10 am to 3 pm for Health Law and Medicaid advice and potential representation. The Access to Benefits number is 888-663-6880.

Yes. You can request a delay or adjournment of your hearing by calling ahead of time or appearing in person. Reasons for a potential adjournment include: you are seeking legal representation, you need more time to gather evidence, or you have an unmovable conflict.

At the hearing, a hearing judge called an “Administrative Law Judge” or “ALJ” will preside over your case. Most hearings are conducted by phone, but if you have a reason that you want to have your hearing in person, you can request that. You will have an opportunity to present evidence demonstrating why the agency’s decision was incorrect. It is possible that a representative from the agency will be there to explain their decision.

If the issue is that your plan determined a service was not medically necessary, it is important to provide medical documentation from your providers demonstrating the medical necessity. If the issue is Medicaid eligibility, you should provide documentation showing that you are eligible. For example, if they denied your application because you are over income, bring recent pay stubs showing that you are under the income limit.

If you need a translator, one must be provided.

A decision will be mailed to you after your hearing. It usually takes around three weeks, but the amount of time varies.
If you win your Fair Hearing and you do not feel the agency has taken the action the decision tells it to, you may request compliance with a Fair Hearing decision. You may submit a Compliance Complaint online or by calling 877-209-1134.

The information in this document has been prepared by The Legal Aid Society for informational purposes only and is not legal advice. This information is not intended to create, and receipt of it does not constitute, an attorney-client relationship. You should not act upon any information without retaining professional legal counsel.