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Family Health Plus (FHPlus) is a public health insurance
program for adults between the ages of 19 and 64 who do not
have health insurance, either on their own or through their
employers, but have incomes too high to qualify for Medicaid.
Single adults, couples without children, and parents with
limited income may qualify for FHPlus.
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Income:
Parent(s) living with a child under the age of 21 will
be eligible if the gross family income is up to 150% of
the Federal Poverty Level.
Individuals without dependent children in their households
will qualify with gross incomes up to 100% of the Federal
Poverty Level.
Social Security benefits (for Disability, Dependent
or Survivors) are counted as income.
Assets:
Not a condition.
Age:
Must be between the ages of 19 and 64 to apply; generally,
college students will not be eligible for FHPlus. Persons
age 65 or over do not qualify for Family Health Plus.
(If they need prescription drug coverage, they may be
eligible for New York State’s Elderly Pharmaceutical
Insurance Coverage (EPIC) program. EPIC’s number
is 1-800-332-3742 (toll-free).
Disability:
Not a condition.
Presence of Spouse:
Not a condition.
Presence of Children:
Not a condition.
Prior Contribution:
Not a condition.
Exhaustion of Benefits From Other
Programs:
Not a condition.
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Job Search (Employment/Work Requirements):
Not a condition.
Participation in Work Program:
Not a condition.
School Attendance:
Not a condition.
Citizenship/Legal Alien Status:
Immigrants in many categories, including lawfully admitted
permanent residents (green card holders) and persons
permanently (legally) residing in the United States,
are eligible to join FHPlus if they meet all other requirements.
In addition, those otherwise eligible qualified aliens
who entered the United States on or after August 22,
1996 may also qualify for FHPlus.
FHPlus is not available to undocumented immigrants
and to immigrants who arrived (or will arrive) in the
United States after August 22, 1996, for a 5-year period
following their arrival.
Other Special Conditions:
Pregnancy:
A pregnant woman applying for health insurance
is not eligible for FHPlus but may receive full coverage
under Medicaid and/or New York's Prenatal Care Assistance
Program (PCAP). However, if a woman becomes pregnant
after enrolling in FHPlus, she will be given the option
of continuing her enrollment year with FHPlus or changing
to Medicaid. Pregnant women should call the Healthy
Baby Hotline at 1-800-522-5006 to get answers to their
questions regarding income eligibility and to find a
PCAP provider near their home or workplace.
Other Insurance:
FHPlus is a health care program for persons who do not
already have health insurance. Individuals should not
drop their insurance in order to apply for FHPlus.
Persons who get health insurance through their employers
are not eligible for Family Health Plus.
Persons who have their own non-employer-based insurance,
COBRA or Healthy NY may, however, be eligible for FHPlus
but they cannot enroll in FHPlus while their other insurance
is still in effect.
Medicare beneficiaries are not eligible for FHPlus
because they already have insurance.
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Type:
FHPlus provides comprehensive coverage, including preventive
care, primary care, hospitalization, prescriptions and
other services. Health care is provided through participating
managed care plans in the area.
Level:
There is no cost to participate in FHPlus. There are
no costs to join and no co-payments or deductibles once
enrolled. There are no sliding scale fees or any other
cost-sharing.
FHPlus provides comprehensive health insurance coverage.
After choosing a health plan, a participant will have
a regular doctor, get regular checkups and see specialists,
if needed.
Coverage includes:
• physician
services;
• inpatient and
outpatient hospital care;
• prescription
drugs and smoking cessation products;
• lab tests and
x-rays;
• vision, speech
and hearing services;
• rehabilitative
services (some limits apply);
• durable medical
equipment;
• emergency room
and emergency ambulance services;
• drug, alcohol
and mental health treatment (some limits apply);
• diabetic supplies
and equipment;
• radiation therapy,
chemotherapy and hemodialysis;
• and dental
services (if offered by the health plan).
Change in Recipient Status:
Once accepted into FHPlus, participants will be guaranteed
6 months of coverage. Renewal is required once every
12 months. Automatic notification will be received by
mail, and the renewal form may be returned by mail.
Mid-year fluctuation in household income and employment
status is not a basis for immediate termination.
To change FHPlus health plans after enrolling participants
can call the local social services district. A participant
has 90 days after joining a plan to decide if that health
plan meets his/her needs. If there is another FHPlus
plan available in the county, the participant can change
health plans at any time during this 90-day period.
After the 90-day trial period, he/she must stay with
the selected health plan for the next 9 months (with
a few exceptions).
Changes in Benefit Levels:
by Act of the New York State legislature and signature
of the Governor. Since Federal funds are available through
a Medicaid waiver, benefits could be affected by an
Act of Congress and signature of the President or by
administrative decisions of Medicaid’s Federal
administering agency, the Centers for Medicare &
Medicaid Services (CMS) of the U.S. Department of Health
and Human Services.
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Where and How
to Apply:
Applicants are required to have a personal interview to
complete an application, provide proof of certain required
information and select a health plan. Enrollment facilitators
are available to help with the enrollment process and
answer questions. Many facilitators are available during
weekend and evening hours at locations around the State.
Local social services districts can also help with the
application process. Local enrollment facilitators
may be selected from the following web site: http://www.health.state.ny.us/nysdoh/fhplus/where.htm
Interested New Yorkers may call the New York State
Health Department's Family Health Plus hotline, at 1-877-9FHPLUS
or 1-877-934-7587, or access the Health Department web
site at http://www.health.state.ny.us
to receive information about the program.
Financing:
FHPlus is paid for with federal, state and local funds.
Half of the cost will be paid with federal Medicaid
dollars. The state share comes from tobacco settlement
money and the tobacco tax. Localities pay 25% of the
cost.
New York applied for and received the federal approval
of Medicaid waivers necessary to implement FHPlus.
Federal Medicaid dollars come from Federal general
revenues, 86% of which are derived from individual and
corporate taxes.
Administration:
The New York State Department of Health (DOH) administers
FHPlus.
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Procedures
for Appeal:
Claimant may ask for a Fair Hearing if the case involves
a denial of medical treatments or denial of benefits.
The plan's internal grievance procedures or its Utilization
Review Appeal procedures may also be utilized.
If unable to solve the problem through the plan's internal
grievance procedures or its Utilization Review Appeal
procedures, the claimant may also be able to use the State's
External Review system.
Fair Hearing, grievance, utilization review, and external
review procedures and rules in FHPlus are the same as
those in the Medicaid managed care program.
Enrollees have the right to ask for a Fair Hearing
before an Administrative Law Judge for most types of
problems. The judge must make a decision within 90 days
of the date when the Fair Hearing was requested. For
an urgent medical problem, the State Fair Hearing Agency
should be able to schedule an expedited Fair Hearing
right away.
A Fair Hearing cannot be immediately requested because
a doctor refuses to provide a specific medical treatment.
Under those circumstances, the first step would be to
go through the plan's internal grievance or utilization
review appeals process. All managed care plans are required
by law to have grievance procedures to help enrollees
resolve almost all complaints. It is better to file
an official grievance than to simply complain orally.
A grievance procedure is an "in-plan process."
This means that the plan's employees (not independent
judges) review the complaint.
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Once the date for the Fair Hearing is assigned, a
free copy of the evidence packet should be requested.
The evidence packet has all the papers that Medicaid
and the Medicaid managed care plan will use at the Fair
Hearing. To get the evidence packet, write:
Ms. Rothbaum
Chief, City Representative and Conference Unit
New York City Medical Assistance Program
Fair Hearings Department
330 West 34th St., 3rd Floor
New York, NY 10001
The Fair Hearing decision should be received in the
mail after a few weeks.
A Fair Hearing may be requested in person, by mail,
phone, or by fax. To request a Fair Hearing in person,
bring a copy of the Denial Notice or Notice of Intent
showing that benefits were going to be cut off or reduced
to the Medicaid Office at:
Medicaid Fair Hearings
330 West 34th St., 3rd Floor
New York, NY 10001
The Fair Hearing Request Form can be faxed, together
with a copy of the Notice of Intent or Denial Notice
(if available), to: 1-518-473-6735. A copy of the fax
confirmation sheet should be kept in order to prove
that the State received the request.
Or, mail the Fair Hearing Request Form, together with
a copy of the Notice of Intent or Denial Notice (if
available) to:
Office of Temporary and Disability Assistance
Fair Hearings
P.O. Box 1930
Albany, NY 12201-1930
Or call: 212-417-6550 or 1-518-474-8781.
A Fair Hearing may be appealed in New York State Supreme
Court. The appeal must be filed within 4 months of the
date of the Fair Hearing decision.
For legal assistance with the appeal, in New York City,
contact the Legal Aid Society's Health hotline at 212-577-3575.
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