Chapter Listing

Medicaid

MAGI Medicaid vs. Non-MAGI Medicaid

Summary

Medicaid is a health benefit for low-income population groups, which includes the aged, blind, disabled, parents/caretaker relatives with dependent children, pregnant women, children, as well as low-income singles/childless couples. The Affordable Care Act (ACA) defined these population groups as either MAGI or non-MAGI. Which income/resources guidelines are used to determine who qualifies, how to apply for or renew Medicaid, how to appeal denials/terminations depends on which population group (MAGI or non-MAGI) the household is designated as.

Certain individuals are automatically or presumptively eligible for Medicaid; these include:

  • SSI recipients,

  • Cash Assistance recipients,

  • Children in foster care, and

  • Juvenile delinquents in the care of OFCS.

Such individuals do not need to apply separately for Medicaid. If in receipt of the benefits/services listed and is renewed, they will continue to receive Medicaid. See above, Automatic Eligibility for Medicaid, for information on these groups.

Medicaid and The Affordable Care Act

There were significant changes/expansions in the Medicaid program under the Affordable Care Act (ACA) for specific population groups, who the ACA labeled as the MAGI populations, (Modified Adjusted Gross Income.) Changes include:

  • Increased income eligibility thresholds;

  • Implementing new income budgeting methodology;

  • Elimination of resource limits;

  • Implementing new application and renewal procedures;

  • Expansion of the Medicaid benefit to cover non-disabled adults ages 19 through 64 who do not have dependent children

    • Please note that NYS had covered this population prior to the implementation of the ACA through a waiver from the federal government.

The non-MAGI populations were not included in the ACA’s Medicaid expansion and continue to operate under the eligibility guidelines, application and renewal procedures in place prior to the implementation of the ACA.

The MAGI Population Groups

MAGI POPULATIONS

The MAGI population groups include the following:

  • Pregnant women;

  • Dependent children under the age of 19;

  • Parents/caretaker relatives of children under 19;

    • Applicants 65 and over, as well as applicants with Medicare, are typically budgeted as non-MAGI.

    • However, if such an applicant is a parent/caretaker relative with children under 19, they may choose to be classified as MAGI and MAGI budgeting rules and application and renewal procedures would apply.

  • Singles/Childless couples ages 19 through 64 who are not entitled to or enrolled in Medicare.

    • This includes SSDI beneficiaries who do not yet have Medicare.

QUALIFYING FOR MAGI MEDICAID

MAGI (Modified Adjusted Gross Income) is the methodology for determining household composition, household size, as well as how income is counted to evaluate eligibility for MAGI Medicaid. The MAGI methodology basically follows the same rules as when a household files their federal income taxes and is based on the adjusted gross income (taxable income) that a filing unit reports on their federal income tax return with certain modifications, thus modified adjusted gross income – “MAGI”. Income thresholds were expanded up to a minimum of 138% of the federal poverty levels (FPL) for the MAGI Medicaid population, and could be higher depending on the applicant. In addition, the asset test was eliminated under the ACA for the MAGI groups. And immigration criteria follow the federal Medicaid immigration criteria, for the most part. For more information, see below, Qualifying for MAGI Medicaid.

APPLYING FOR MAGI MEDICAID

Most MAGI applicants apply online at the NY State of Health Insurance Marketplace. However, there are a few exceptions. Local counties and HRA in NYC will continue to handle the following type of cases for MAGI applicants/recipients:

  • Medicaid Spenddown participants;

  • Managed Long-Term Care Plan participants;

  • Assisted living participants;

  • All Medicaid consumers who need long-term nursing home care, institutional Medicaid;

  • Adults or children in need of waiver services;

  • Consumers residing in a congregate care facility.

For more information, see below, Applying for MAGI Medicaid.

MEDICAID RENEWAL FOR MAGI RECIPIENTS

MAGI recipients will renew through the NY State of Health Marketplace, unless they are subsequently transferred back to the local district because they receive certain Medicaid services, as listed above. For more information, see below, Medicaid Renewal for MAGI Recipients.

The Non-MAGI Population Groups

NON-MAGI POPULATIONS

The non-MAGI populations were not included in ACA’s Medicaid expansion and continue to operate under the eligibility guidelines, application and renewal procedures in place prior to the implementation of the ACA. The non-MAGI population groups include:

  • Aged – 65 and over

  • Disabled with Medicare

  • Blind with Medicare

The only exception to this rule is when a Medicare beneficiary or an individual 65 or over is a parent or caretaker relative with children under 19. If this were the case, they may choose to be classified as MAGI and MAGI budgeting methodology, application and renewal procedures would apply.

For more information, see below, Qualifying for Non-MAGI Medicaid, Non-MAGI Population Groups.

QUALIFYING FOR NON-MAGI MEDICAID

A non-MAGI disabled, blind or aged applicant follows the same eligibility and income and resource budgeting methodology that were in place prior to the ACA. For more information, see below, Qualifying for Non-MAGI Medicaid.

The one exception to this is for people age 65 and over who are without documentation; as of January 1, 2024, this population is eligible for non-MAGI Medicaid. Prior to this change, this population only qualified for Emergency Medicaid. If individuals in this category were already enrolled in Emergency Medicaid on the NY State of Health Marketplace, their case remained there and was transitioned to full Medicaid. Uninsured individuals in this category should apply for Medicaid at their local Department of Social Services (LDSS), HRA in New York City. Regardless of whether their Medicaid case is with the Marketplace or HRA, all individuals in this category are required to enroll in a managed care plan.

APPLYING FOR NON-MAGI MEDICAID

Non-MAGI applicants apply at a local county’s Medicaid office; HRA in NYC. For more information see below, Applying for Non-MAGI Medicaid.

MEDICAID RENEWAL FOR NON-MAGI RECIPIENTS

Non-MAGI recipients renew their Medicaid at their local county’s Medicaid office; HRA in NYC. For more information see below, Medicaid Renewal for Non-MAGI Recipients.

The Medicaid Benefit Package

In NYS, the Medicaid benefit package is the same for both the MAGI and the non-MAGI population groups, see above, Description of Medicaid, Benefit Package.

The Medicaid Chapter

The following sections in the Medicaid chapter have been split by MAGI or Non-MAGI Medicaid as follows:

  • Qualifying for MAGI Medicaid

  • Applying for MAGI Medicaid

  • Medicaid Renewal for MAGI Recipients

  • Qualifying for non-MAGI Medicaid

  • Applying for Non-MAGI Medicaid

  • Medicaid Renewal for Non-MAGI Recipients

  • MAGI Advocacy and Appeals

  • Non-MAGI Advocacy and Appeals

Other sections in the Medicaid chapter, including Description of Medicaid, Documentation, Medicaid Managed Care Provisions, Medicaid Community Based Long-Term Care Services, Institutional Medicaid, Additional Medicaid Benefits, Government Contacts have not been split into separate sections. Information within these sections will specify differences, if any, between these two population groups.

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