OVERVIEW OF PROGRAMS

The Medicaid and S-CHIP (Child Health Plus or CHPlus) programs in New York are administered by the State Department of Health, Office of Medicaid Management.  The S-CHIP program is a combination Medicaid Expansion (CHPlus A) and separate program (CHPlus B).  There is a joint application for both programs.

Eligibility for both programs is determined by the State Department of Social Services at the county/local level, except in New York City, where the Human Resources Administration determines eligibility.   For a listing of county offices and a listing of HRA program offices in the five boroughs of NYC, go to www.health.state.ny.us/nysdoh/medicaid/ldss.htm.  The state has contracted with 31 community-based organizations or “facilitated enrollers” who are responsible for enrolling children in either CHPlus A or B.  Facilitated enrollers provide families with necessary information, assist in completing applications and submitting applications and required documentation to the local social services district for enrollment in CHPlus A or contracted health plans for enrollment in CHPlus B.

Certain types of income are disregarded, and certain deductions from income apply, depending on the eligibility category.

Home, car and personal property are generally exempt from resource tests.

Note:  Individuals enrolled in Managed Care Plans are guaranteed six months of coverage in the health plan, even if they lose Medicaid eligibility.

MEDICAID

Categories for Adults

Pregnant Women

Income cannot exceed 200% of FPL.
No resource limit.

Authorized providers may make presumptive eligibility determinations for pregnant women.

Breast and Cervical Cancer Program

Income cannot exceed 250% of FPL.
Must be uninsured.
Resource limit?

Women must be screened through the Healthy Woman Partnerships program and be found in need of treatment for breast or cervical cancer.

Single Adults/Childless Couples Age 21 to 65

Income is compared to the Public Assistance Standard of Need for the applicant.
Income cannot exceed 185% of the Public Assistance Standard of Need and cannot exceed 100% of FPL.

The Public Assistance Standard of Need consists of six separate items whose value must be added together to arrive at a needs level for a particular applicant/recipient.

Parents Living with Dependent Children under Age 21

Income cannot exceed Medically Needy income levels (see chart below).
Resource limit:  $3,000 per household

Qualified and Unqualified Aliens

Must meet the eligibility requirements of any category.

An otherwise eligible alien who is either:
·         Permanently residing in the U.S. under color of law; or
·         Is a qualified alien subject to the five-year ban
is no longer limited to Medicaid coverage for treatment of an emergency condition.
Otherwise eligible qualified aliens may be eligible for Medicaid benefits with State and local funds.

Only those individuals who are not citizens, qualified aliens or permanently residing in the US under color of law (PRUCOL) are limited to emergency medical services under the Medicaid program.

Family Planning Benefit Program (FPBP)

Income cannot exceed 200% of FPL.

These individuals have access to all enrolled Medicaid family planning providers and family planning services currently available under Medicaid.

Categories for Families/Children

Infants up to age 1 (Child Health Plus A)

Income cannot exceed 200% of FPL.
No resource limit.

A child born to a Medicaid-eligible mother remains eligible for Medicaid until the end of the month in which the child turns age 1, providing the child continues to live with the mother.

Children age 1 through age 18 (Child Health Plus A)

Income cannot exceed 133% of FPL.
No resource limit.

Children under age 19 with incomes below 250% of FPL are presumptively eligible for either Medicaid or S-CHIP for 2 months or until eligibility determination is made.

Children age 19 to 21

Income cannot exceed Medically Needy income levels (see chart below).
Resource limit:  $3,000 per household.

Foster Children

Children receiving Title IV-E foster care payments are automatically eligible for Medicaid.
Children in non-IV-E foster care must qualify in an appropriate eligibility category.

Temporary Assistance for Needy Families (TANF)

Aid to Families with Dependent Children (ADC)-Related

Must have a deprivation.
Income and resources cannot exceed Medically Needy levels (see chart below).

The ADC program no longer exists as a cash grant program, however, Medicaid continues to have this ADC medically needy category.

Deprivation refers to the absence of or un/under-employment of one or both parents or caretaker relatives.

Low Income Families (LIF)

Income is compared to the Public Assistance Standard of Need for the applicant.  Income cannot exceed 185% of the Public Assistance Standard of Need and cannot exceed 100% of FPL.
Resource limit:  $3,000 per household.

Includes families with children under age 21, children under age 21 who are not living with caretaker relatives, caretaker relatives and pregnant women.

This category includes families with and without a deprivation of parental support or care due to continued absence, death, incapacity or under/unemployment.

The Public Assistance Standard of Need consists of six separate items whose value must be added together to arrive at a needs level for a particular applicant/recipient.

Medically Needy

See chart below for income and resource limits by family size.

These individuals meet the programmatic requirements of their respective categories but exceed the income requirements.  They may use medical expenses to “spend down” their income to qualify for Medicaid. 

Elderly/Disabled

Aged, Blind and Disabled receiving Supplemental Security Income (SSI)

Generally, these individuals are automatically eligible for Medicaid.
Income cannot exceed approximately 74% of FPL according to Social Security Administration standards.
Resource limit:  $2,000 for one person, $3,000 for two people.

These individuals receive full Medicaid coverage.

Aged, Blind and Disabled not receiving SSI

Income limits:
1 person: $642/month
2 people: $934/month

Resource limits:
1 person:  $3,850
2 people:  $5,600

These individuals receive full Medicaid coverage.

Medicare Buy-In Program

·         Qualified Medicare Beneficiary (QMB)

·         Specified Low Income Medicare Beneficiary (SLIMB)

·         Qualified Individual (QI-1)

Income cannot exceed 100% of FPL.

Income above 100% of FPL but cannot exceed 120% of FPL.

Income above 120% of FPL but cannot exceed 135% of FPL.

Resource limits for QMB, SLIMB and QI-1:
1 person:  $4,000
2 people:  $6,000

For QMBs, Medicaid pays for either the Medicare Part A or Part B premium and all deductibles and coinsurance.

For SLIMBs and QI-1s, Medicaid pays Medicare Part B premium.

Qualified Working Disabled Individuals (QWDIs)

Income limits:
1 person:  $1,525/month
2 people:  $2,049/month

Resource limits:
1 person:  $4,000
2 people:  $6,000

Medicaid pays Medicare Part A premium.

Working Disabled

Income cannot exceed 250% of FPL.

These individuals receive full Medicaid coverage.

Program began April 1, 2003.

This program is state-funded only.

SCHIP

Child Health Plus B for children age 1 to 19

Income (after disregards) must be greater than 133% of FPL but cannot exceed 250% of FPL.

There are monthly premiums based on income level.  Families with incomes between 160% and 222% of FPL pay $9 per child per month, up to a maximum of $27 per month per family.  Families with incomes between 223% and 250% of FPL pay $15 per child per month, up to a maximum of $45 per month per family.
Families with incomes below 160% of FPL and American Indians/Alaska Natives pay no premiums.

Children under age 19 with incomes below 250% of FPL are presumptively eligible for either Medicaid or S-CHIP for 2 months or until an eligibility determination is made.

Number in Family

Monthly Net Income

Assets

1

$642

$3,850

2

$934

$5,600

3

$942

$5,650

4

$950

$5,700

5

$992

$5,950

6

$1,134

$6,800

7

$1,275

$7,650

8

$1,417

$8,500

Each additional person

$142

$850