Purpose: This study examines variation in emergency department reliance (EDR) between rural and metro pediatric Medicaid patients in New York State for noninjury, nonpoisoning primary diagnoses and seeks to determine the relationship between receipt of preventive care and the likelihood of EDR. Methods: Rural/urban designations were based on Urban Influence Codes established by the United States Department of Agriculture (USDA). Healthcare Effectiveness Data and Information Set (HEDIS[R]) well-visit measures were calculated using 2008 Medicaid claims and encounter data. Well-child numerator status and location of residence variables were then entered as independent variables in multivariate logistic regression models. Models controlled for the effects of Medicaid financing system (fee-for-service vs managed care), Medicaid aid type, race/ethnicity, gender, and 2008 clinical risk group category. Findings: The likelihood of EDR was higher in all age categories for rural compared to metro residing Medicaid children in New York State. Meeting HEDIS well-child criteria was protective against emergency department (ED) reliance in the adolescence age group (OR = 0.84). Conclusion: ED reliance is associated with rural residence. Increased access to primary and specialty care in rural settings could help reduce EDR, particularly among rural adolescents.