Q. What Is Medical Assistance (MA)?

A.     Medical Assistance (also called Medicaid) is help for people who cannot pay for all of their medical care.

Q. Who May Get Medical Assistance?

A. You may get Medical Assistance if you:

· Meet certain income, resource, age, disability or other requirements

or

· Get Public Assistance (PA) or Supplemental Security Income (SSI)

Q. How Do I Apply For Medical Assistance?

A.  When you are applying for or getting Public Assistance or Supplemental Security Income, you do not have to fill out a separate application for Medical Assistance.

·If you are not applying for or getting Public Assistance or Supplemental Security Income:

- Contact the Wyoming County Department of Social Services at 786-8900.

- If you are a patient of one of the following, contact the office listed after the name of the facility:

· New York State Office of Mental Health facility - Patient Resource Office

· New York State Office of Mental Retardation and Developmental Disabilities facility -Revenue Support Field Office

· New York State Veterans' Home (Oxford Veterans' Home) - Medical Assistance Office

· You must fill out an Application and check the Medical Assistance box.

Q.How Can Medical Assistance Help Me?

A. Medical Assistance may help you pay for:

· Health Insurance Premiums

· Hospital inpatient and outpatient services

· Laboratory and X-ray services

· Care in a nursing home

· Treatment and preventive health and dental care (doctors and dentists)

· Treatment in psychiatric hospitals (for persons under 21, or 65 and older), mental health facilities, and mental retardation and developmental disabilities facilities

· Family planning services

· Medicine and supplies

· Clinic services

· Emergency ambulance transportation to a hospital

· Other health services

Medical Assistance may also help pay for the following, but you or the person in the facility providing the service must have the service approved ahead of time (prior approval):

· Transportation to medical appointments, including bus tokens and car mileage.

· Personal care

· Home health care (usually)

· Durable medical equipment (wheelchairs, orthopedic shoes, etc.)

· Long term health care in the home, under the Long Term Health Care Program (LTHCP). This is care in the home that is very much like nursing home care, for people who require home care for more than 90 days and who need nursing or therapy services. ~his program is not available in all districts.)

If you are pregnant or have a child, the following programs may be able to help you:

· Prenatal Care AssIstance Progrem (PCAP) - If you are pregnant, the Prenatal Care AssIstance Progrem can help you get the care you need to have a healthy baby. You can have a high income and still get care from PCAP. There is no limit to the amount of resources you may have. At your first PCAP visit, a worker will help you apply for Medical Assistance. For more information about this program, call the Healthy Baby Hotline at 1-800-522-5006.

· WIC - You may also get WIC (Special Supplemental Food Program for Women, Infants and Children) -The WIC Program provides helpful information about nutrition and the importance of eating healthy foods. The WIC program provides checks which can be exchanged in participating stores for infant formula, milk, juice, eggs, cheese, cereal, peanut butter, dry peas and beans.

For more information about the WIC Program and where you can apply, call 1-800-522-5006.

· Child/Teen Health Plan (CITHP) - The Child/Teen Health Plan is a way for children and teens to get the medical exams and follow-up care they need to make sure they are healthy and growing right.

The Child/Teen Health Plan is for children and teens up to age 21 who have Medical Assistance.

It is free of charge.

The Child/Teen Health Plan gives your children:

· Complete medical exams

· Hearing, lab, and eye tests

· Any shots they may need

· Referrals for dental care

For more information about this program, or for help finding a doctor for your child, ask the (CITHP) coordinator at your local department of social services.

· Managed Care Progrems will also help you to find a doctor who can give you prenatal care and will continue to see you and your child for exams and follow-up after your pregnancy.

Q. How Does Medical Assistance Work?

A. After an application is approved, most persons will get a plastic card called a Benefit Identification Card. When you get medical care, tell them that you have Medical Assistance and give this card to the doctor, pharmacist or other person you want help from. Your bills will be sent to the State to be paid.

Q. Do I Pay Any Money For My Medical Care?

A. Medical Assistance recipients age 21 or older may be asked to pay part of the costs of some medical care/items. This is called a co-payment or co-pay. Your health care provider is allowed to ask you for the co-payment. For each 12 months beginning April 1,1994, there is a $100 maximum per recipient for all co-payments.

If you are unable to pay the requested co-payment, tell your health care provider when the provider asks you for payment. You can still get the services you need from your provider. The provider cannot refuse to give you services or goods because you tell the provider that you are unable to pay the co-payment. Call 1-800-541-2831 to report any provider who refuses to give you care or services because you are unable to pay the co-payment.

Co-payment amounts are as follows:

Recipients exempt from co-payment include the following:

- Recipients under the age of twenty-one;

Exempt services include the following:

- Emergency services;

NOTE: Co-payments are not charged by private practicing physicians and dentists or, for home health and personal care services.

Q. How Often And How Much Medical Assistance Help Can I Get?

A. The number of times medical Assistance will pay for visits to doctors or clinics, labs and drug stores may be limited. This limit is called "Medicaid Utilization Thresholds". Your worker can tell you if Medicaid Utilization Thresholds apply to you.

Q. What is A Medicaid Managed Care Program?

A. Many counties have a Medicaid Managed Care Program through either a Health Maintenance organization (HMO) or a clinic, hospital, or physician group office. When you join a managed care program, you can choose a personal doctor who will be responsible for making sure all your health care needs are met. That doctor will send you to someone else if you need more help than they can give.

Q. Why Join a Managed Care Program?

A. You will not have to look for a doctor who takes Medical Assistance or go to an emergency room because you cannot find a doctor. Your personal doctor will take care of you and your children. When you need other help that your doctor cannot give you, your doctor will find it for you.

If you are pregnant, your doctor will be able to give you all the visits and tests you need, and will make sure that you and your baby have follow-up visits after the baby is born. Any of your children can be seen by a doctor.

There are no co-pays or utilization thresholds when you join a managed care program. All managed care patients are given an insurance card separate from the Medicaid card.

Q. Can Medical Assistance Pay For Past Medical Bills?

A. Medical Assistance may be able to pay medical bills for care you were given during the three months before you applied for help. Remember to tell your worker if you have any paid or unpaid medical bills.

Q. Can Medical Assistance Pay For Medical Care I Get Outside Of New York State?

A. Maybe. Medical Assistance will pay for medical care you get out of state if:

· People from your county usually get medical care in that state; or

· Your local department of social services put or helped put you in a nursing home or foster care in another state; or

· Your doctor has gotten approval for you to get medical care out of state (prior approval); or

· You need emergency medical care while traveling in another state.

Q. What Is Medicare?

A. Medicare is not the same as Medical Assistance (Medicaid). Medicare is a federal insurance program administered by the Social Security Administration that pays for hospital bills (Part A) and doctor bills and some other medical services (Part B). You can apply for Medicare at your local Social Security Office.

Q. Can Medical Assistance Pay My Medicare Premiums?

A. Yes, under certain conditions, Medical Assistance may pay for Medicare premiums.

Q. Should I Cancel Any Other Health Insurance I Already Have?

A. No. Wait and ask this question at your interview.

Q. Where, Besides Social Services, Can I Get Money To Help With My Health Insurance Costs?

A. You may be able to get a Health Insurance Tax Credit. Call your local Internal Revenue Service (IRS) for more information.

Q. Can I Still Keep Some Of My Income If I Am In A Nursing Home Or Other Medical Facility?

A. Yes. You can keep a small amount for your own personal use. You can also keep some of your income and resources for your family if they are dependent on you.

Q. Can a Lien (Legal claim) Be Put On My Home?

A. If you are in a medical institution, we may put a lien on your real property, including your home. Your worker can give you more information.

Q.   If I Am Pregnant Or Have Children, Can I Have More Income And Resources And Still Get Medical Assistance?

A. Yes, if you are pregnant or want help for a baby under the age of one, there is no limit to the amount of resources (savings) a family, you or the child can have.

If you want help for a child born on or after October 1, 1983, there is generally no limit to the amount of Resources the family can have.

Q.   What If I Have Emergency Medical Needs?

A. New York State law requires hospitals to give you emergnecy care, even if you cannot pay for it. If you have a medical emergency, like a heart attack or other life threatening illness, before you find out if you are able to get Medical Assistance or before you have applied for Medical Assistance, go to a hospital rlght away.

If you are sick and need medical care right away, and you have applied for but have not gotten your Benefit ID card, your worker may be able to help you get a temporary card for the medical help you need. You must show the card when you get medical treatment.

Medical Assistance may be able to pay medical bills for care you were given during the three months before you applied for help. Remember to tell your worker if you have any paid or unpaid medical bills.

Q.  What Is Prospective Drug Utilization Review?

A. The Prospective Drug Utilization Review Program lets a pharmacist check a computer before you get your prescription filled to see if you recently received any other medicines that should not be taken with your new prescription. If the pharmacist sees a problem, he may check with your doctor to find out if you should be given the new medicine. This is done to make sure you get the right medicine. Your pharmacist, by checking with the computer, will also be better able to answer any questions you may have about your medicines.

Q.   If I Sell, Give Away Or Transfer Any Money Or Property, Can I Still Get Medical Assistance?

A. This section explains what may happen if you transfer any property or money and apply for Medical Assistance. A transfer is when you give away money or property or sell property for less than it is worth.

You can keep certain money or property for you and your family and still get Medical Assistance. If you or your spouse transferred other money or property, Medical Assistance may not pay for the following medical care for a period of time, depending on how much money or property you transferred.

1. Care in a nursing home

2. Certain care in your own home, which is like nursing home care.

3. Care you get in a hospital, when you no longer need hospital care and you are waiting for nursing home care

However, Medical Assistance will pay for other medical care if you are eligible.

In most cases if you want full Medical Assistance coverage, you cannot transfer money or property.

Sometimes, you can transfer money or property and still get full Medical Assistance coverage if:

· You transfer money or property to your husband or wife.

· You transfer money or property to your child who is blind or disabled. The local department of social services where you are applying must decide if your child is blind or disabled.

· The property transferred was your home, and it was transferred to husband, wife, child under age 21 or child of any age who is blind or disabled. The local department of social services where you are applying must decide if your child is blind or disabled.

· You transfer your home to your brother or sister who already has a right to part of your home and lived in the home for a least one year immediately before you went into a nursing home facility. You may transfer your home to your child if your child was living in your home at least two years immediately before you entered a nursing home and your child took care of you, so that you could stay home rather than go into a nursing home.

· You set up a trust for a disabled individual. The local department of social services must decide if the individual is disabled.

When the local department of social services decides that you have transferred any property or money and you think that the district has made a mistake, you have a right to prove that you did not transfer the property or money by:

· Proving that you meant to sell the property for what it was worth or to get something else of equal value in exchange

· Proving that you got rid of the money or property only for some reason other than to get the medical care listed above (1, 2 or 3)

· or

· Proving that despite all your attempts, you cannot get the money or property back or get something of equal value, and that you cannot get the medical care you need without Medical Assistance. You must work with the local department of social services in trying to get the money or property back.

NOTE: For information about what might happen if you transferred property or money before August 11, 1993, ask your local department of social services.

Medical Assistance Utilization Thresholds Fact Sheet

There are limits on the number of times you can receive certain medical services throughout the Medical Assistance Program.

There are no limits on the following services:

- family planning services

- methadone maintenance treatment

- obstetric services (pregnancy)

- care given under a managed care program

- kidney dialysis

- child teen health plan

- other services - call 1-800-421-3891.

Benefit Year:

Service limits are for a 12 month period called a benefit year which begins the month you become eligible for Medical Assistance. You will have these same limits even if you go on and off Medical Assistance during this benefit year. After the benefit year is over a new 12 month benefit year will begin with the full number of service limits (for example: 18 laboratory tests). Services not used from the last benefit year will not be carried over to the new benefit year.

During each benefit year we will keep track of the number of services you are using and will let you know by mail if you are using services quickly and are in danger of reaching your limit. We will also let you know by mail if you have reached your service limit.

MA Benefit Identification Card:

When you go for a medical service, your doctor, clinic or pharmacy must first check with Medical Assistance to see whether you have reached the limit for medical services. it is important that you show your plastic "Benefit Identification Card" each time you go for medical services.

If You Need More Services: Your doctor can fill out a special form called a "Threshold Override Application", to ask Medical Assistance to increase the number of services you can receive or to give you an exemption from service limits.

· you or other household members have a serious illness or are sick a lot;

or

· you get a letter from Medical Asssistance warning you that you are using services quickly and are in danger of reaching your service limit;

or

· you get a letter from Medical Assistance telling you that you have reached your service limit.

IF YOU NEED SERVICES ABOVE YOUR LIMIT MAKE SURE THAT YOU ASK YOUR DOCTOR TO FILL OUT THE THRESHOLD OVERRIDE APPLICATION. REMEMBER, IF YOU DO NOT ASK FOR MORE SERVICES AND YOU REACH YOUR LIMIT, MEDICAL ASSISTANCE WILL NOT PAY FOR ADDITIONAL SERVICES EXCEPT FOR EMERGENCY MEDICAL CARE, UNTIL YOUR NEW BENEFIT YEAR BEGINS.

Managed Care Programs:

If you enroll in a Managed Care Program you will not be subject to the Utilization Threshold Program. To find out if there is a Managed Care Program available to you, please call your local social services district.

If You Have Any Questions:

You may call 1-800-421-3891 Monday to Friday-9am to 5pm and someone will help you.

Fair Hearing Rights:

You have a right to a Fair Hearing when your application for an exemption or an increase in service limits is denied and you have reached your service limits. At this hearing you can raise the issue of whether we correctly figured the number of services you used.