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

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Strategies for Maximizing Access to Health Care
for Persons Living with HIVNavigating the
Maze of Eligibility Criteria in New Yorks
Public Health Care Programs

• Presented by
• Trilby de Jung, Esq.
• Empire Justice Center
• March 27, 2008

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Todays 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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Broad Overview
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• 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
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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

FHP
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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 years 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)

ADAP
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Program Overlap

FHP
CHP A
Medicaid
ADAP
Spend

CHP B
down
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Eligibility Levels
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Medicaid Eligibility

• Income and resource levels will vary depending on
  your clients 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
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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

Medicaid
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Medicaid Spend Down Program

• Your clients 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
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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

Medicaid
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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

Medicaid
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CASE EXAMPLE
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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?

Medicaid
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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)

FHP
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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

CHP
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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)

CHP
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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

CHP
Family Income Proposed Monthly Premium
251-300 FPL 20 per child 35 child 60 max 105 max
301-350 FPL 30 per child 55 child 90 max 165 max
350-400 FPL 40 per child 75 child 120 max 225 max
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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
• Resources must be less than 25,000

ADAP
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Budgeting
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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 clients 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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Budgeting

• The MRG is the caseworkers 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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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

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CASE EXAMPLE
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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 Lisas 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
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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
  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

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Due Process Rights
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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
  https//www.otda.state.ny.us/oah/oahforms/erequest
  form.asp

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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 programs website to review service
  package,
• then look to medical necessity -- need doctors
  support

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Summary
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To Summarize

• Weve 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
• 585-295-5722