presented by trilby de jung esq empire justice center march 27 2008
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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
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
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
slide4
Medicaid
  • 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

Medicaid

family health plus fhp
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

FHP

child health plus chp
Child Health Plus (CHP)

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
aids drug assistance program adap
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)

ADAP

program overlap
Program Overlap

FHP

CHP A

Medicaid

ADAP

Spend

CHP B

down

medicaid eligibility
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

Medicaid

medicaid income levels for single childless couples
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

Medicaid

medicaid spend down program
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)

Medicaid

medicaid spend down cont
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

Medicaid

medicaid spend down cont14
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

Medicaid

medicaid spend down example
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?

Medicaid

family health plus fhp eligibility
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)

FHP

child health plus chp a
Child Health Plus (CHP) A

CHP

  • 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
child health plus chp b
Child Health Plus (CHP) B

CHP

  • 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)
child health plus chp b20
Child Health Plus (CHP) B

CHP

  • 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
aids drug assistance program adap eligibility
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

ADAP

budgeting
Budgeting
  • 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
budgeting24
Budgeting
  • 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.
budgeting25
Budgeting
  • 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
budgeting example
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

budgeting example cont
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

other eligibility criteria
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
other eligibility criteria31
Other Eligibility Criteria
  • The Deficit Reduction Act requires citizens to provide proof of both citizenship and identity
    • For a list of acceptable documents visit http://www.health.state.ny.us/health_care/medicaid/

publications/docs/gis/06ma021att.

    • 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
right to notice fair hearing
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:https://www.otda.state.ny.us/oah/oahforms/erequestform.asp
timelines for hearings
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
issues to look for
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
to summarize
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
your advocacy can make a difference
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

585-295-5722

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