Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

Other Services

Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: New York (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes	$3/visit clinic services excluding ambulatory surgery		10 clinic visits/year in combination with other specified providers	Prospective cost based rate	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes	$3/visit to Public Health Clinic		10 visits/year for Public Health Clinic medical care in combination with other specified providers and 3 visits/year for dental care, 40 visits/year for Mental Health Clinic care	Fee for service or prospective cost based rate	CN & MN
Federally Qualified Health Center Services
Yes	$3/visit		10 clinic visits/year in combination with other specified providers	Prospective cost based rate	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	$25/admission			Prospective payment/discharge using DRG, prospective per diem for specialty hospitals/units, some services may be paid on a fee for service basis	CN & MN
Outpatient Hospital Services
Yes	$3/visit		10 outpatient visits/year in combination with other specified providers	Prospective all-inclusive rate with limits, some services fee for service	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes				Fee for service	CN & MN
Rural Health Clinic Services
Yes	$3/visit		10 clinic visits/year in combination with other specified providers	Prospective cost based rate/visit	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
No
Chiropractor Services
No
Dental Services
Yes		Specified services	3 visits/year (limit applicable to dental clinics but not dental offices)	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes				Fee for service	CN & MN
Nurse Midwife Services
Yes				Fee for service	CN & MN
Nurse Practitioner Services
Yes				Fee for service	CN & MN
Optometrist Services
Yes			1 refractive exam/2 years, visual aids covered when visual acuity criteria met	Fee for service	CN & MN
Physician Services
Yes			10 visits/year in combination with other specified providers	Fee for service	CN & MN
Podiatrist Services
No
Psychologist Services
Yes				Fee for service	CN & MN
Prescription Drugs
Prescription Drugs
Yes	$1/generic Rx or preferred or less costly brand Rx , $3/brand Rx, $.50/over the counter product	Specified drugs	40 Rxs/year	AWP-16.25% for brand Rx, AWP-25% for generic Rx, plus $3.50 dispensing fee for brand Rx or $4.50 dispensing fee for generic Rx, specialized HIV pharmacies paid AWP-12%	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
Yes				Fee for service	CN & MN
Physical Therapy Services
Yes				Fee for service	CN & MN
Services for Speech, Hearing and Language Disorders
Yes				Fee for service	CN & MN
Products and Devices
Dentures
Yes		Yes		Fee for service	CN & MN
Eyeglasses
Yes		Special lenses and other specified services	1 pair eyeglasses/2 years	Fee for service	CN & MN
Hearing Aids
Yes		New or replacement hearing aid		Acquisition cost plus dispensing fee for hearing aid, other services/items paid fee for service	CN & MN
Medical Equipment and Supplies
Yes	$1/order	Specified med equipment and med supply items		Fee for service, some items paid invoice cost plus percentage	CN & MN
Prosthetic and Orthotic Devices
Yes		Specified services or items		Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes				Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes		Yes		See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes				Fee for service	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes	$.50/lab test, $1/x-ray		18 lab tests/year	Fee for service, and using Medicare payment ceilings for lab services	CN & MN
Targeted Case Management
Yes				Fee for service	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Services for the following populations: 1, 2, 3, 4, 6, 7 & 8 - See service-specific FN	Dependent upon the services provided	CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes		40 visits/year and must be in lieu of hospitalization	Prospective cost based payment	CN & MN
Hospice Care
Yes			Prospective rates based on Medicare methodology	CN & MN
Personal Care Services
Yes	Initiation of care and at 6 month intervals	Services provided at 2 levels, must be supervised by RN	Fee for service	CN & MN
Private Duty Nursing Services
Yes	Yes	Limited to situations where home health agency care is not available or not cost effective	Fee for service	CN & MN
Program of All-Inclusive Care for the Elderly
Yes		See service-specific FN	Capitated payment	CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes			Prospective cost based per diem, some services may be paid on a fee for service basis	CN & MN
Inpatient Psychiatric Services, under age 21
Yes			Prospective cost based all-inclusive per diem, some services may be paid on a fee for service basis	CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes			Prospective cost based per diem with limits	CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes			Prospective per diem based on cost using peer groups and acuity adjusted	CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has an approved Section 1115 Waiver from CMS under which it implemented The Partnership Plan. The waiver extended healthcare coverage to low-income adults previously covered under the former State-funded cash assistance Safety Net program and moved many Medicaid beneficiaries from a primarily fee for service delivery system to a mandatory managed care environment. A subsequent waiver amendment created the Family HealthPlus (FHPlus) program for additional low-income uninsured adults under the age of 65. The benefits package for FHPlus beneficiaries is less comprehensive and requires higher copayments for services. FHPlus does not include long-term care services for the chronically ill, non-emergency medical transportation, medical supplies or non-prescription drugs except for smoking cessation products, and limitations apply to home health and inpatient psychiatric care as well. The tables do not reflect the benefit and cost sharing parameters of the FHPlus program. This State has also added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA). These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits on a fee for service basis, if their income is at or below 250 percent of the federal poverty level (FPL), however an income-based monthly premium is charged based on income above 150 percent of the FPL.