New York State's Request for an Amendment to its Current Section 1115 Waiver
New York State is pleased to submit this amendment to its current Section 1115 waiver, building upon its existing Partnership Plan to expand the availability of health insurance to the uninsured, working poor. Under the new program called Family Health Plus (FHPlus), this amendment will strengthen New York State's health care system offering comprehensive health care coverage to more than 600,000 low-income adults who have incomes or assets above the current New York Medicaid levels. These individuals do not have access to health insurance coverage or cannot afford it.
The FHPlus program is the result of an unprecedented consensus among government leaders and key consumer and advocate groups, labor organizations and health care providers. Under Governor Pataki's leadership, the State legislature enacted this program as part of the Health Care Reform Act of 2000 (HCRA 2000). Together with the State-funded "Healthy New York" program, which will provide employers more affordable health insurance, HCRA 2000 offers significant new options for health care coverage in New York State.
This amendment to the Partnership Plan requests the additional waivers of several provisions of the Medicaid program so that New York State can expand eligibility for certain groups and receive federal financial participation in the costs of the FHPlus program.
Eligibility Under the Family Health Plus Program
The FHPlus program will provide comprehensive health care coverage to adults, with and without children, who have incomes or assets greater than the current Medicaid eligibility standards. Individuals meeting the following criteria will be eligible to enroll in FHPlus:
- Permanent residents of New York State.
- Age 19 through 64.
- Citizens or Medicaid eligible qualified aliens.
- Not eligible for Medicaid based on income and/or resources.
- Not in receipt of "equivalent" health care coverage or insurance.
Parent(s) living with a child under the age of 21 will be eligible if the gross family income is up to:
- 120% of the Federal Poverty Level (FPL) as of January 1, 2001;
- 133% FPL as of October 1, 2001; and,
- 150% FPL as of October 1, 2002.
Individuals without dependent children in their households will qualify with gross incomes up to 100% FPL.
While the majority of Medicaid eligibility standards and rules will apply, several aspects of the program will require waivers to encourage participation and ease enrollment. There are no asset or resource tests for FHPlus, nor any co-payments, premiums or other types of cost sharing. Similar to Child Health Plus (CHPlus), New York's extraordinarily successful health insurance program for children, coverage is available when eligibility is determined and enrollment in a plan has occurred (i.e., there is no retroactive coverage). Enrollees will be guaranteed an initial six months of coverage regardless of changes in circumstances. The existing Medicaid fair hearing and notice process will be used for eligibility determinations under FHPlus.
Applicants with equivalent health insurance, as defined under the Health Insurance Portability and Accountability Act, will not be eligible for FHPlus. Moreover, to prevent employers from reducing their current commitments to provide health insurance ("crowd out"), current insurance availability will be measured during the application process. The State will monitor changes in insurance coverage among applicants. Should "crowd out" occur, the enabling legislation requires that individuals wait six months (with certain specified exceptions) before they are able to enroll in FHPlus.
Services Provided under the Family Health Plus Program
A comprehensive benefits package, similar to that provided under the State's CHPlus program, will be provided to individuals enrolled in FHPlus. Services will be provided through managed care organizations and will include:
- Physician services;
- Inpatient and outpatient health care;
- Prescription drugs;
- Smoking cessation products;
- Lab tests and x-rays;
- Vision care;
- Speech and hearing services;
- Durable medical equipment;
- Home health service (short term, acute care in lieu of hospitalization, up to 40 visits per year);
- Family planning services and supplies;
- EPSDT services;
- Emergency room services;
- Emergency ambulance transportation;
- Inpatient mental health and alcohol and substance abuse treatment (30 days per year);
- Outpatient mental health and alcohol and substance abuse services (60 visits per year);
- Diabetic supplies and equipment;
- Radiation therapy, chemotherapy and hemodialysis; and,
- Dental services (to the extent offered by the plan).
Similar to CHPlus and commercial and employer-sponsored health insurance plans, long-term care services, non-prescription medications (except smoking cessation products) and non-emergency transportation are not covered under FHPlus. Moreover, because all services are to be provided through managed care plans, there are no "wrap-around" fee-for-service provisions.
Family Health Plus Service Delivery System
An initial Request for Application will be distributed to the 37 insurers already participating in Medicaid managed care or CHPlus. Plans will be screened for current financial stability, positive survey outcomes and network capacity. By using existing plans with the proven ability to meet quality assurance, access and reporting requirements, the service delivery system will be more reliable and effective.
Despite plan recruitment efforts, it is possible that fewer than two FHPlus plans may be available in a county, particularly in low density or rural areas of the State. While only one FHPlus plan may be the sole option for obtaining care, network requirements provide choices between and among providers. In areas where there is insufficient managed care capacity, State legislation also enables the State to purchase a prepaid benefit package from a commercial insurer.
Rates will be developed utilizing the existing Medicaid managed care rate setting process. Rates will be all inclusive and fully capitated, without carve-outs.
The State will monitor the quality of care provided by FHPlus plans using a system built upon the existing Partnership Plan Quality Monitoring Plan. Key components of the monitoring will include internal quality improvement systems within plans, external monitoring and data collection, on-site reviews, and consumer satisfaction surveys. Grievance and appeals processes will assure that both the plans and the State provide full access for participant's complaints, and protection of their rights.
Application and Enrollment Processes
The FHPlus legislation streamlines the eligibility and enrollment process. A simplified application form will be designed to screen and assess eligibility for Medicaid, CHPlus and FHPlus. The application and annual recertification processes will be integrated with traditional Medicaid eligibility reviews to assure that applicants are directed to the appropriate program. Care will be taken to assure that applicants who are eligible for traditional Medicaid will be enrolled in that program.
Effective transitions will be established between Medicaid, FHPlus and CHPlus, so that when changes in income, resources, or age occur, continuity of care is assured. For example, those enrolled in traditional Medicaid, but found ineligible during recertification based on income or resources, will be assessed for FHPlus. Young adults who become ineligible for CHPlus based on age will be assessed for Medicaid and FHPlus.
While local social services districts will continue to be able to accept applications for Medicaid and FHPlus, the program will also use enrollment facilitators to ease the application process. Our initial feedback concerning this approach in the CHPlus program, upon which the FHPlus program will build, has been very positive.
Enrollment facilitators will be sited at community locations and at convenient times for working families and individuals. It will be their responsibility to assist individuals in completing the combined and streamlined application for the various programs. These community based groups will be fully trained to screen applicants for eligibility under all programs, using a joint Medicaid/CHPlus/FHPlus application with standardized definitions and a simplified format.
The facilitators will also provide impartial and helpful information to assist in the selection of a participating plan and a primary care physician. Household members will be encouraged, but not required, to participate in the same plan as other FHPlus, CHPlus or Medicaid managed care family members. Because FHPlus is a voluntary, rather than mandatory program, no auto-assignment will be used.
The annual recertification process will also be eased by the use of a mail-in process, and availability of enrollment facilitators to provide assistance.
Outreach and Publicity
New York State will develop a comprehensive plan for FHPlus outreach that will complement and build upon the efforts currently in place for the CHPlus program. FHPlus will be marketed as a health insurance program for low-income individuals and families and will be targeted to reach potentially eligible populations.
In addition to statewide publicity, education and outreach activities, facilitators and plans will also be an important source of information about the availability of FHPlus. Protections are built into the FHPlus program to ensure that such activities are conducted appropriately.
Family Health Plus Administration
The Department of Health (DOH) will administer the FHPlus program. The DOH is the designated Title XIX single state agency, and is responsible for administration of the current Partnership Plan waiver as well as the CHPlus program. FHPlus administrative functions will be integrated with current Partnership Plan and CHPlus activities such as expansion of the enrollment facilitator activities, rate setting, quality assurance monitoring, patient survey, research and reporting. This approach will reinforce the goal of assuring continuity of care and effective management and oversight, while avoiding establishing new and duplicative administrative structures.
Purpose and Outcomes
This waiver amendment will allow New York State to continue to address the original Partnership Plan waiver objectives of quality assurance, access, improved health outcomes and cost effective service delivery. Other outcomes of the demonstration will include:
- Supporting the goals of welfare reform by assuring that employed individuals are able to continue working with adequate health insurance.
- Testing the effectiveness of a CHPlus-type service package for adults.
- Promoting health insurance as an item that is obtained for a family as a whole, rather than only individual members of a family.
- Assuring seamless transitions for individuals between and among the CHPlus, Medicaid, FHPlus and Healthy New York health insurance programs.
- Identifying and testing means to streamline obtaining and maintaining eligibility in publicly funded programs, transitioning New York State Medicaid from a perceived "welfare" support to a health insurance program.
- Assuring that individuals and families seeking health coverage are given the opportunity for a "full" Medicaid determination.
Research and Evaluation
The FHPlus demonstration will provide timely information for New York State and the Health Care Financing Administration to:
- Understand the size, nature and utilization patterns of an expansion population which is currently uninsured.
- Provide information on the effectiveness of a facilitated and simplified enrollment process.
- Measure the continuity of care and health outcomes for CHPlus "graduates."
- Determine whether the availability of insurance leads to a greater likelihood of retaining employment.
- Assess the improvements in prudent health service use through managed care.
- Determine the impact on existing employer insurance plans when publicly funded insurance coverage is introduced.
Waivers and Amendments Requested
New York State is requesting waivers of certain statutory and regulatory requirements necessary to implement FHPlus as defined in State legislation. While several waivers have already been approved under the original Partnership Plan, additions, modifications and amendments are required based on the nature of this new program. In summary, the major waivers being requested include:
- Eligibility standards and income and resource requirements, so that individuals with higher incomes than current Medicaid standards can enroll in the program and that we can modify the "disregard" process to ease the eligibility process.
- Amount, duration and scope of services, so that the comprehensive package of services can be provided, although the package is not equal to that provided under the traditional Medicaid program.
- Statewideness and freedom of choice, to reflect that the types and degree of selection of managed care plans may not be comparable statewide and that services will only be provided through a managed care insurance product.
Similarly, the budget neutrality formula, and the detailed terms and conditions under the Partnership Plan will require amendments and revisions. While many of the Terms and Conditions are applicable to FHPlus, others are not, such as those associated with auto-assignment, mandatory placement in managed care, requirements for special needs plans, phased in implementation and others.