Medicare, Medicaid, Home Care, and Mental Health Services in New York: Who Covers What?

When someone needs help at home or wants to see a therapist, it can be difficult to know which insurance card to use. In New York, the answer depends on the service, the person’s coverage, and the type of plan they have.

Medicare and Medicaid can both cover health care, but they serve different roles. New York Medicaid members may receive benefits directly through the state or through a managed care plan. People who have both Medicare and Medicaid may have separate plans for medical care and long-term care, or an integrated plan that coordinates them.

Home care: Medical visits or help with daily activities?

Medicare home health care may cover intermittent skilled nursing, certain therapies, and limited home health aide services when a person meets Medicare’s requirements. These generally include needing qualifying skilled services and being homebound. Medicare does not cover 24-hour care at home or ongoing personal care when personal care is the only service needed.

New York Medicaid may cover longer-term help with activities such as bathing, dressing, toileting, grooming, and meal preparation when the person qualifies and the service is assessed and authorized. Depending on the person’s coverage, those services may be arranged through a Medicaid managed care plan, a Managed Long Term Care (MLTC) plan, or another applicable Medicaid pathway. New York’s Consumer Directed Personal Assistance Program (CDPAP) is a separate option for eligible members who select and hire their own caregiver.

An important distinction: A Medicare-covered nurse or therapist visiting the home does not automatically mean Medicare will pay for a long-term personal care aide.

What about mental health and behavioral health care?

Mental health and behavioral health services can include an evaluation, individual or group therapy, psychiatric visits, medication management, and certain substance use disorder services. More intensive services may be available when clinically appropriate.

Medicare Part B covers qualifying outpatient mental health services, including visits with psychiatrists, psychologists, clinical social workers, and other eligible professionals. Medicare also covers certain substance use disorder services. If someone has a Medicare Advantage plan, they should check that plan’s provider network and coverage rules.

New York Medicaid also covers outpatient mental health care. For a member in a mainstream Medicaid managed care plan, the plan’s network and member handbook are the starting points for finding covered care. A Health and Recovery Plan (HARP) is a specialized Medicaid managed care plan for eligible adults with significant behavioral health needs; qualifying members may have access to additional behavioral health home and community-based services.

Which plan should you contact?

Coverage shown on your cards| Home care questions| Outpatient mental health questions Medicare only| Ask Medicare or your Medicare Advantage plan about qualifying home health services. Long-term personal care is generally outside Medicare’s home health benefit.| Ask Medicare or your Medicare Advantage plan about covered clinicians, costs, and network rules. New York Medicaid fee-for-service (“straight Medicaid”)| Ask the Medicaid office or care coordinator which assessment and authorization process applies.| Ask whether the clinician or clinic accepts New York Medicaid fee-for-service for the specific service. Mainstream Medicaid managed care| Contact the plan about covered home care, assessments, and authorization.| Contact the plan for its behavioral health network and coverage rules. HARP| Contact the plan about covered medical and home care services.| Contact the plan about therapy, psychiatry, substance use services, and any additional services for which you qualify. Medicare plus a partial-capitation MLTC plan| The MLTC plan generally arranges covered Medicaid long-term care; Medicare or a separate Medicare plan handles Medicare-covered medical services.| Start with your Medicare coverage for Medicare-covered treatment. Ask the provider and both plans how any Medicaid-covered portion is handled. Medicaid Advantage Plus (MAP) or PACE| Contact the integrated plan about home care and long-term services.| Contact the integrated plan about its mental health providers and benefit rules.

These are types of coverage, not a list of insurance companies. A company may offer more than one type of plan, and a provider’s participation can differ by product. Check the exact plan name on your card and confirm participation with both the plan and the provider. New York lists partial MLTC, MAP, and PACE as distinct long-term care arrangements; MAP includes Medicaid behavioral health benefits in its plan benefit package.

What do the billing codes mean?

Providers use billing codes to describe the care delivered. Common examples in outpatient mental health include 90791 for a psychiatric diagnostic evaluation, 90834 for a 45-minute psychotherapy service, and 90837 for a 60-minute psychotherapy service. New York identifies these and other mental health procedure codes in its Medicaid payment guidance for qualifying Article 28 clinics.

A code does not, by itself, establish coverage or payment. The provider’s license and enrollment, clinic type, diagnosis, documentation, applicable rate code, medical necessity, and the member’s specific plan all matter. For example, an Article 28 clinic billing straight Medicaid may follow different claim and payment rules from that same clinic billing a Medicaid managed care or Medicare Advantage plan.

If you are scheduling care, you do not have to determine the billing code yourself. Ask the provider: “Do you accept my exact plan for this service, and do I need an authorization or referral?”

Four questions to ask before starting care

1. What service is needed? Skilled care at home, ongoing personal care, therapy, psychiatry, or a combination?
2. What are the exact plan names? Show the provider every Medicare and Medicaid card.
3. Who must assess or authorize the service? Ask this before assuming that a visit or aide schedule is approved.
4. Does this provider accept this specific plan for this specific service? Confirm with the provider and the plan.

If a person’s needs change, contact their clinician and plan or care manager to ask whether a new assessment or treatment authorization is needed. The correct payer and process can change with the service—even when the patient and provider stay the same.

This article provides general information. Individual coverage depends on eligibility, the specific benefit and plan, provider participation, medical necessity, and applicable authorization and billing rules.