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Strategies for Maximizing Access to Health Care for Persons Living with HIV: Navigating the Maze of Eligibility Criteria in New York’s Public Health Care Programs. Presented by: Trilby de Jung, Esq. Empire Justice Center March 27, 2008. Today’s Agenda.

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Presented by trilby de jung esq empire justice center march 27 2008 l.jpg

Strategies for Maximizing Access to Health Care for Persons Living with HIV:Navigating the Maze of Eligibility Criteria in New York’s Public Health Care Programs

Presented by:

Trilby de Jung, Esq.

Empire Justice Center

March 27, 2008

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Today’s Agenda

  • We will discuss eligibility for four major programs used by persons w/HIV/AIDS:

    • Medicaid

    • Family Health Plus

    • Child Health Plus

    • ADAP

  • Broad Overview of Programs

  • Financial Eligibility & Budgeting

  • Due Process Rights

  • Helpful Resources

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  • Critical source of health care coverage for people with HIV/AIDS -- advocacy crucial

  • Welfare-related program, created in 1965 as an entitlement

  • Joint federal-state program, significant county involvement in NYS

  • Federal law prescribes minimum services and mandatory populations

  • State law adds other services and populations, builds patchwork of programs


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Family Health Plus (FHP)

  • State program created in 2000 under a federal waiver - unique to NYS

  • Medicaid expansion program intended to reach low-income adults

  • Services through private managed care plans, less comprehensive

  • Entitlement program for states and recipients because part of Medicaid


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Child Health Plus (CHP)


  • Began as a state program in NY in 1990

  • Federal program in added in 1997 (SCHIP)

  • NY utilizes “combination approach”

    • CHP A is Medicaid program for children

    • CHP B a managed care program for non-Medicaid eligible, less comprehensive

  • Expansion up to 400% of poverty level passed last year – blocked by CMS

  • This year’s budget uses state only dollars

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AIDS Drug Assistance Program (ADAP)

  • Federal program created in 1987, provides grants to states – no entitlement

  • Allows states to set their own formularies

  • In NY we have four separate programs:

    • Regular ADAP (prescription drugs) – important bridge to Medicaid

    • ADAP plus (primary care)

    • HIV home care

    • ADAP plus insurance continuation program (APIC)


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Program Overlap








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Medicaid Eligibility

  • Income and resource levels will vary depending on your client’s category

  • Eligibility levels for elderly, disabled, caretakers, and children ages 19-21 are about 87% of the federal poverty level (FPL):

    • $725/mo for one

    • $1067/mo for two

  • Resource limit is $4,350 for one/ $6,400 for two – budget proposes higher level

  • Spend down is available to this category of clients


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Medicaid Income Levels for Single & Childless Couples

  • Income must be below the Safety Net Assistance Level – 50% of FPL

  • No Spend down available for this group

  • Resource limits:

    • $2000 for single adults & childless couples up to age 50

    • $3000 for single adults & childless couples ages 60-64


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Medicaid Spend Down Program

  • Your client’s spend down amount = income above the eligibility level (after budgeting disregards)

  • Medical expenses that qualify:

    • Health insurance deductibles and co-pays (not premiums)

    • Bills for necessary medical expenses NOT covered by Medicaid

    • Bills for medical expenses covered by Medicaid

    • Expenses by state or locally funded programs (including ADAP payments and CHP premiums)


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Medicaid Spend Down (cont.)

  • Bills need only be incurred, they need not be paid

  • Your client can use bills incurred by other people in the household

    • Anyone in the household who is also applying for Medicaid

    • Anyone in the household your client is legally responsible for, even if they are not applying


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Medicaid Spend Down (cont.)

  • If your client is a new applicant to Medicaid, she can use PAST bills to meet spend down

    • Paid bills can be up to three months old

    • Unpaid bills can be used as long as they are “viable”

  • Your client must bring in the bills within 3 months of receiving the notice, or reapply

  • Medicaid is generally certified for a period from one to six months (carry over only for unpaid bills)

  • Clients can pre-pay spend down by paying in to the local social services district


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Medicaid Spend Down Example

  • Leo, your client, is a 45 year old man with AIDS who has a disability determination and receives SSDI

  • Leo applies for Medicaid. In June he receives a notice saying he is eligible with a monthly spend down of $50.00

  • Leo has no medical bills. In October, his 19 year old son who lives with him is hospitalized for a broken leg

  • Leo receives a bill for $800.00

  • Is Leo now eligible for Medicaid? What are his options?


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Family Health Plus (FHP) Eligibility

  • FHP is for adults ages 19-64 who have no other insurance

  • Parents and caretakers eligible up to 150% of FPL

  • Single adults and childless couples cannot have income above 100% of FPL

  • New asset test:

    • Household of one – $13,050 (2008)

    • Household of two - $19,200 (2008)


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Child Health Plus (CHP) A


  • Children under one year of age can have incomes up to 200% of the FPL

  • Children between 1-5 years of age can have income up to 133% of FPL

  • Children 6-18 years of age must have income below 100% of FPL

    • $843 for household of one

    • $1,133 for a household of two

  • No resource test for CHP A or B

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Child Health Plus (CHP) B


  • CHP B is available for children who are not Medicaid eligible, regardless of income

  • Free for incomes up to 160% of FPL

  • Between 160% and 222% of FPL, premiums of $9/mo per child

  • Between 222% and 250% of FPL, premiums of $15/mo per child

  • Above 250%, full premium (average reported to be between $120 and 150/mo)

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Child Health Plus (CHP) B


  • Expansion would eliminate “cliff” effect after 250% of FPL

  • Provide gradual decreases in subsidy up to 400% of FPL

  • State only proposal raises the cost sharing

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AIDS Drug Assistance Program (ADAP) Eligibility

  • ADAP, ADAP Plus and APIC are for persons with HIV-infection HIV Home Care requires higher medical need.

  • Income level is more than 400% of the FPL

    • $44,000 annually for one

    • $50,200 annually for two

  • Resourcesmust be less than $25,000


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  • Need to know budgeting to help client decide whether to apply & check for mistakes by caseworker

  • First step is decide which budgeting rules apply – what is client’s category?

    • AFDC-related

    • SSI-related

    • Safety Net related

  • If client falls into more than one category, entitled to use most favorable

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  • The MRG is the caseworker’s bible for budgeting & other eligibility rules

    • MRG in three sections with comprehensive table of contents.

    • MRG will provide you with cites to statute, regulations and policy directives.

  • First step, household size.

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  • For AFDC and Safety Net related clients, the household will include:

    • All non-SSI/PA members applying for Medicaid, and

    • Any non-SSI/PA who are legally responsible, regardless of whether applying

  • For SSI-related clients:

    • household will always be one or two.

    • deeming & allocation rules apply

  • Some types of income can be disregarded – list of disregards for each category is in the MRG

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Budgeting Example*

  • Lisa is an HIV+ single mom with a 4 year old son, Jimmy.

  • What is the maximum amount of family income for Lisa to get Medicaid?

  • What about for Jimmy to get Medicaid?

  • How does the situation change if Lisa also has a 2nd child, Jenny, who is 16?

    TIP: Use Income Chart in Appendix 1

    *facts developed by:

    Lisa Sbrana

    Health Law Unit

    Legal Aid Society

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Budgeting Example (cont.)

  • Now assume Lisa and her 2 kids, with gross earned income of $1800/mo.

  • Can Lisa get Medicaid?

  • What about the kids?

  • What happens if Lisa gets a raise to $2,250/mo?

  • What if Lisa’s health declines (AIDS related) and she is hospitalized?

  • What are her options if she needs home care?

    TIP: Use Income Chart in Appendix 1 & Medicaid Income Disregards Charts in Appendix 4

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Other Eligibility Criteria

  • Your client must be a resident of New York State to be eligible for Medicaid, CHP, FHP and ADAP

  • No minimum time requirement but client must intend to stay

  • Subsequent to Aliessa decision, legal immigrants can access Medicaid, CHP, FHP and ADAP

    • See ADM in Appendix 6 for categories of qualified immigrants

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Other Eligibility Criteria

  • The Deficit Reduction Act requires citizens to provide proof of both citizenship and identity

    • For a list of acceptable documents visit


    • Exceptions for those with SSI and/or Medicare, and for children in foster care

  • CHP B and ADAP are open to NYS residents regardless of immigration status

  • Emergency Medicaid and the Prenatal Care and Assistance Program (PCAP) are also open to NYS residents regardless of immigration status

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Right to Notice & Fair Hearing

  • When Medicaid services are denied, reduced or terminated, your client has the right to notice & a fair hearing

  • Adequate notice must contain an accurate statement of the grounds for the negative decision and information regarding a fair hearing

  • Your client is entitled to a fair hearing even where no notice - requests are made to the Office of Temporary & Disability Assistance (OTDA)

  • Requests can be made online at:

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Timelines for Hearings

  • Clients have only 60 days to request a fair hearing after receiving adequate notice of the denial or termination

  • If the hearing is requested with 10 days, your client can get aid continuing

  • A decision must be made on the evidence within 90 days of the date on which your client requested the hearing

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Issues to look for

  • Budgeting errors, especially with spend down

  • Delays in processing

    • General rule is 45 days for decision

    • 90 days when disability determination is involved

    • 30 days for pregnant women

  • Payment on bills

    • Medicaid and CHP A are retroactive for three months (CHP B and FHP are not)

  • Service denials

    • visit program’s website to review service package,

    • then look to medical necessity -- need doctor’s support

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To Summarize:

  • We’ve looked at the general parameters, eligibility rules for four major programs

  • Be aware others exist (PCAP, Emergency Medicaid, Medicaid Buy-in, Part D, Waiver programs for LTC/mental health services)

  • Introduced you to basic tools:

    • Income and Resource Chart

    • Medicaid Reference Guide

    • Administrative Directives

  • Lots more resources at the websites listed in Module 7

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Your advocacy can make a difference!

  • Your clients really need your help

  • Remember, UHF estimates that 45% of uninsured people in New York are eligible for a public health program

  • Call me for if you have questions:

    Trilby de Jung

    Empire Justice Center

    Rochester, NY