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A. Who is Eligible for Family Health Plus? Family Health Plus (“FHP”) is a Medicaid expansion program for adults ages 19 to 65 who are not otherwise eligible for Medicaid. . It covers adults without children with income up to 100% of the FPL and adults with children up to 150% of the FPL. In 2007, the legislature created two important extensions of Family Health Plus coverage -- the Family Health Plus Premium Assistance Program, which helps low-income workers pay for employer sponsored insurance, and the Family Health Plus Buy in Program, which allows employers and unions to buy-in to FHP to provide health insurance to their workers/members. for more information about the Family Health Plus Premium Assistance Program, which is up and running, click on the links in this paragraph. Implementation of the Family Health Plus Buy in Program has been more limited. The program began with members of Union 1199 and will expand to other employers/unions in the near future.
a. AGE -- applicants must be between the ages of 19 and 64
b. INCOME -- FHP covers adults without children with income up to 100% of the FPL and adults with children up to 150% of the FPL. The current income levels and information about FHP eligibility generally are posted on the SDOH website at: http://www.health.state.ny.us/nysdoh/fhplus/who_can_join.htm.
d. Must be uninsured. See N.Y. Soc. Servs. L. § 369-ee et. seq. Some exceptions have been established to the uninsured requirement. See GIS 08 MA/007 Family Health Plus: Excepted Benefits for an explanation of these exceptions. Pre-existing conditions are not a bar to FHP coverage. e. Some people may be eligible for FHP OR Medicaid with a spend-down. See FHP Enrollment below. All FHP enrollees must enroll in a FHP managed care plan and most services, including family planning, are provided through the plan. As of October 2011, pharmacy benefits are included in the managed care plan benefit package, after having been "carved out" since October 2008. See this article on pharmacy benefits in managed care and the Pharmacy Benefit Information Website at http://pbic.nysdoh.suny.edu. Applicants join a FHP managed care plan for a 12-month period, with the right to switch plans without cause for the first 90 days. An enrollee may change plans for good cause during the next 9 months. Family members do not have to join the same FHP plan.
FHP enrollees receive primary, preventive, specialty and inpatient care. FHP dental benefits are optional which means the health plans determine whether they will cover dental care (those plans that do cover dental benefits get rate adjustments from the Department of Health). For enrollees, this means if they chose a plan that does not cover dental benefits, they have no dental care. There is no fee-for-service coverage for dental services.
Although FHP enrollees, like all Medicaid recipients, have a duty to report changes that affect their eligibility, FHP enrollees have guaranteed coverage for their first six months of enrollment, even if their income goes above the guidelines. N.Y. Soc. Servs. L. §369-ee(3)(c). In November 2008, the state has requested a waiver from the federal government to extend guaranteed eligibility from six months to 12 months. CMS has not yet responded to this request.
FHP will not pay for long-term care services for the chronically ill, like nursing home stays, personal care services, hospice care, intermediate care facilities for the developmentally disabled and private duty nursing. FHP does cover up to 40 home care visits in lieu of hospitalization. FHP also does not cover non-emergency transportation, medical supplies, non-prescription medications (other than diabetic supplies and equipment). See N.Y. Soc. Servs. L. §369-ee(1)(E); 01 OMM/ADM-6 (Attachment VI describes FHP benefit package); see also Medicaid Managed Care/Family Health Plus Model Contract, Appendix K.
FHP has co-payment requirements for many services. However, although providers can bill, as with Medicaid these services cannot be denied if the enrollee cannot afford to pay the co-pay. See 05 OMM/ADM-4 Family Health Plus Program Changes Required by Chapter 58 of the Laws of 2004, Chapters 58 and 63 of the Laws of 2005; see also Medicaid Reference Guide (MRG), pp 398-399.
When applying, applicants should be informed about whether they are eligible for Medicaid and/or FHP. Not all people eligible for FHP could also be eligible for Medicaid with a spend-down. Only those under age 21 or those adults age 21+ whose dependent child lives with them may use spend down. See information on Medicaid spend-down. If the applicant is eligible for full Medicaid (with no spend-down) she cannot enroll in FHP.
However, if the applicant is only eligible for MA with a spend-down (exxcess income), she can choose to enroll in FHP instead. N.Y. Soc. Servs. L. §369-ee(2)(a)(2); 01 OMM/ADM-6 Eligibility Requirements for the Family Health Plus Program, Facilitated Enrollment of Adults into Medicaid and Family Health Plus at 11-12. Pre-existing conditions are not a bar to FHP coverage.
Factors to help decide whether to enroll in FHP or Medicaid with a Spend-down, for those who have a choice:
Applicants can apply for FHP by completing the Access NY Health Care Application. As of April 1, 2010, in-person interviews are no longer required as part of the application process. See 10 OHIP/ADM-4. Although in-person interviews are no longer required, assistance with the application can be obtained by contacting a community based facilitated enroller, a local Medicaid office or by contacting participating managed care plans directly. The enroller will submit the completed application within 5 days of the signature on the application. The local Medicaid office must make a determination on eligibility within 30 days from the date of the application for households with pregnant women and/or children and 45 days for all others.
Public assistance recipients with children under 21 in their household should be offered transitional Medicaid when their work income makes them ineligible to continue to receive public assistance. When their transitional Medicaid is ending, the family should receive a separate redetermination for MA/FHP eligibility. A seamless transition should occur from Medicaid to FHP for these families. See 01 OMM/ADM-6 at 20-22.
Medicaid/FHP for Singles/Childless Couples
Single and childless couples who are deemed ineligible for Safety Net Assistance but whose income is below 100% of poverty will continue to receive Medicaid pending a separate determination. A similar seamless transition should occur from FHP to Medicaid for individuals whose earnings dip. See 01 OMM/ADM-6 at 20-22.
Newborns
All babies born to a woman who is enrolled in FHP will be provided 1 year’s automatic Medicaid coverage. N.Y. Soc. Servs. L. §366(4)(1); 01 OMM/ADM-6 at 15-17. The baby will either be placed in the mother’s plan (on Medicaid managed care if her county is a mandatory county), or if her plan does not participate in Medicaid, in the Medicaid managed care plan of her choice. If there is no Medicaid managed care plan in the mother’s district, baby will enroll in fee-for-service Medicaid.
Recertification
FHP uses an annual mail-in recertification process.
FHP beneficiaries can request Fair Hearings (see Fair Hearing discussion in Medicaid section) or seek to resolve their problems through internal plan grievance, N.Y. Pub. Health L. §4408-a, and/or utilization review procedures, N.Y. Pub. Health L. §4900.
This article was authored by the Health Law Unit of the Legal Aid Society.
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