1. 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

2. 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

3. Broad Overview

4. 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

5. 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

6. 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 CHP

7. 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

8. Program Overlap FHP FHP CHP A ADAP Medicaid CHP B Spend down

9. Eligibility Levels

10. 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

11. 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

12. 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

13. 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

14. 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

15. CASE EXAMPLE

16. 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

17. 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

18. 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

19. 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

20. 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 IncomeProposed 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

21. 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

22. Budgeting

23. 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

24. 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.

25. 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

26. CASE EXAMPLE

27. 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 2 nd child, Jenny, who is 16? TIP: Use Income Chart in Appendix 1 *facts developed by: Lisa Sbrana Health Law Unit Legal Aid Society

28. 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

29. Other Eligibility Criteria

30. 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

31. 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/ 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

32. Due Process Rights

33. 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/erequestfor m.asp https://www.otda.state.ny.us/oah/oahforms/erequestfor m.asp

34. 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

35. 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

36. Summary

37. 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

38. 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