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

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) 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

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 CHP A Medicaid ADAP Spend CHP B 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 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

19. 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)

20. 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

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 • Resourcesmust be less than $25,000 ADAP

22. Budgeting

23. 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

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 2nd 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. 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

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/ 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/erequestform.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