Key points
- NY State of Health is the official marketplace, and people may qualify there for Medicaid, Child Health Plus or the Essential Plan.
- In Medicaid managed care, the state's model handbook makes your PCP the starting point for specialist referrals.
- Members with long-term illnesses may be able to choose a specialist as their PCP.
- Plans change their own rules: UnitedHealthcare's NY Medicaid plan dropped referrals for certain specialist follow-up visits on January 1, 2026.
This page explains the general structure of coverage and referrals from official sources. It isn't advice about your coverage or your care. Referral rules, networks and covered services vary by plan and change over time, so confirm details with your plan and your member handbook before you book.
Getting covered: NY State of Health
NY State of Health is New York's official health plan marketplace. Through it, people may qualify for free or low-cost coverage through Medicaid, Child Health Plus or the Essential Plan. The individual coverage section is the place to start if you're looking for coverage for yourself or your family.
| Option | Where to start | What to ask about eye specialists |
|---|---|---|
| Marketplace health plan | NY State of Health | Is this ophthalmologist in network, and is a referral needed? |
| Medicaid | NY State of Health | Am I in managed care, and who is my PCP? |
| Child Health Plus | NY State of Health | How does my child get a referral to an eye specialist? |
| Essential Plan | NY State of Health | Does my plan require a PCP referral for specialists? |
We don't cover eligibility rules here. Use NY State of Health's own pages to see which options you may qualify for.
Medicaid managed care: how specialist referrals work
If you have Medicaid through a managed care plan, the state's model member handbook lays out the basic structure. The version we cite is a 2010 revision, so treat your own plan's current handbook as the version that applies to you.
- Choose a primary care providerMedicaid managed care members choose a PCP.
- Start with your PCPIf you need care your PCP can't give, raise it with your PCP first.
- Get the referralUnder the model handbook, your PCP refers you to a specialist for care the PCP can't provide.
- Book with the specialistWhen you call the ophthalmology office, mention the referral and ask them to confirm it's on file.
If you have a long-term illness
The model handbook says members with long-term illnesses may be able to pick a specialist as their PCP. Whether that's possible in your case, and with which kind of specialist, is a question for your plan.
Who to contact about managed care
For questions about Medicaid managed care itself, the model handbook says members can contact their local Social Services Department or New York Medicaid CHOICE.
We weren't able to confirm whether New York Medicaid managed care plans let members self-refer for eye care. Don't assume either way. Ask your plan before booking.
Plans change their rules: the UnitedHealthcare 2026 example
Referral rules aren't fixed. Starting January 1, 2026, UnitedHealthcare's New York Medicaid plan no longer requires referrals for follow-up visits with certain specialist types. Visits beyond that follow-up still need a PCP referral. If you're a member, check the plan's notice to see which specialist types are included.
This applies to one plan. It isn't a statewide rule, and it doesn't tell you what any other plan requires. It's a useful reminder that last year's answer may not hold this year, so check again whenever you start a new round of specialist visits.
Which call to make first
| Your situation | Contact first | Why |
|---|---|---|
| No coverage yet | NY State of Health | To see whether you may qualify for Medicaid, Child Health Plus, the Essential Plan or a marketplace plan |
| Medicaid managed care, new eye concern | Your PCP | Under the model handbook, the PCP refers you to specialists |
| Questions about Medicaid managed care itself | Local Social Services Department or New York Medicaid CHOICE | The model handbook names both as contacts |
| Long-term illness, want a specialist as PCP | Your plan | Members with long-term illnesses may be able to choose a specialist as PCP |
| UnitedHealthcare NY Medicaid, follow-up visit | Your plan or PCP | Since January 1, 2026, some specialist follow-ups no longer need a referral |
| Any other plan | Your plan's member services | Referral and network rules are plan-specific |
Questions to ask your plan
- Do I need a referral to see an ophthalmologist, and does it cover one visit or several?
- Is this specific ophthalmologist, at this specific location, in my network?
- Does a follow-up visit need a new referral?
- If I have a long-term illness, can a specialist serve as my PCP?
- Where can I find the current member handbook for my plan?
Questions to ask the ophthalmology office
- Do you take my specific plan, including Medicaid managed care or the Essential Plan if that's what I have?
- Do you have my referral on file?
- Which location and which doctor will I see?
- What should I bring to the visit?
Before the visit, you can also check the doctor's license and board certification and, if you're heading to an academic center, look up verified locations and phone numbers. Our home page summarizes the whole process.
Frequently asked questions
Do I need a referral to see an ophthalmologist in New York?
There's no single answer; it depends on your plan. In Medicaid managed care, the state's model handbook says your PCP refers you to a specialist when you need care the PCP can't give. Check your own plan's rules before booking.
Can I see an ophthalmologist without a referral on Medicaid?
We couldn't confirm whether New York Medicaid managed care allows self-referral for eye care. Ask your plan before booking so there are no surprises.
Can an ophthalmologist be my primary care provider?
The model handbook says members with long-term illnesses may be able to pick a specialist as their PCP. Whether that can be an ophthalmologist in your case is a question for your plan.
What changed with UnitedHealthcare in 2026?
Starting January 1, 2026, UnitedHealthcare's NY Medicaid plan no longer requires referrals for follow-up visits with certain specialist types. Visits beyond that follow-up still need a PCP referral. The change applies to that plan only.
Where do I apply for Medicaid, Child Health Plus or the Essential Plan?
NY State of Health, the state's official health plan marketplace, is where people may qualify for free or low-cost coverage through those programs.
Can this site check my coverage?
No. We're an independent guide, not a health plan or a medical practice, and we can't review personal coverage or health information. Contact your plan, your local Social Services Department or New York Medicaid CHOICE directly.
Sources
- Medicaid Managed Care Model Member Handbook — NYS Department of Health
- Medicaid Managed Care Model Member Handbook (PDF, 2010 revision) — NYS Department of Health
- NY Medicaid specialist referral requirement update — UnitedHealthcare