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*As of 01/01/06 Child Health Plus A allows families to deduct certain expenses (such as child care, health insurance costs and limited work expenses) and certain types of income (such as income from a full time student under 21, SSI and Public Assistance) when determining eligibility. The chart is meant only as a rough guide. Families should consult a facilitated enroller or their local Medicaid office for a full eligibility determination. Finally, children up to age 21 with special health needs that require the comprehensive benefits package of Child Health Plus A may enroll in Medicaid even if their income is above eligibility guidelines. This program is called the Excess Income or "Spend down" program. Children and adults with disabilities can also qualify for Medicaid or the "Spend down" program using special rules for counting their income; see chapter 5A for more information about these programs. CHILD HEALTH PLUS BQ. What is Child Health Plus B? A. Child Health Plus B covers many children under 19 who are not eligible for Child Health Plus A. Some of these children live in families that earn too much to be eligible for Child Health Plus A, but not enough to be able to afford private insurance. Child Health Plus B
is only available through managed care plans!
All children enrolled in Child Health Plus B receive their care from managed care plans. At the time of application, families must choose a health plan for their child from among those that serve their borough or neighborhood. Most of the Child Health Plus B plans in New York City are also Medicaid Managed Care Plans. Q. What does Child Health Plus B cost? A. How much a family pays depends on how much the family earns per month. For some families, Child Health Plus B is free. Some families have to pay a small monthly amount. If the family’s income makes them eligible for subsidized coverage they will only need to pay a monthly premium of $9 or $15 for each child (up to 3 children. For more than 3 children, they would only pay $27 or $45 each month for the family.) If the family income is higher, they would pay the full premium. There are no co-payments for individual visits or other services. Please see the following table. Monthly Income Levels for Child Health Plus BFind a family's monthly income below to see what your cost may be for Child Health Plus B.
*The full premium varies, depending on the Child Health insurance plan you choose, but is about $135.00 per child with no maximum limit. Q. How does a family apply for Child Health Plus A and B? A. Families can apply for Child Health Plus A and B at authorized enrollment sites in their neighborhoods, called “facilitated enrollers." Facilitated enrollments sites include places like community centers, day care centers, schools, and the local Medicaid office. Many Medicaid Managed Care plans are also authorized to enroll children into Child Health Plus A or B. The facilitated enrollment sites have staff to help families fill out the application form, screen their children for Child Health Plus A or B, and gather the necessary documents. (Facilitated enrollers can also help adults enroll and submit applications for Medicaid and Family Health Plus). The application form is easy to fill out. It is 8 pages long, and called the “Growing Up Healthy” form. It can be accessed electronically here. A copy can also be found at the end of this chapter (print version only). The “Access NY Health Care” form is an alternative form that can also be used for children applying for Child Health Plus A or B (as well as for adults applying for Family Health Plus or Medicaid- See Chapter 5 and11 for more details). It can be accessed electronically here. For Child Health Plus B, a plan must be selected at the time of enrollment. Staff at the enrollment sites can help families select a plan and fill out the necessary forms.
Families will be asked to provide several documents along with their application to verify their eligibility, including proof of age, address, income, citizenship or immigration status (not needed for Child Health Plus B) and identity. Families are allowed to deduct from their income certain expenses, including childcare and health insurance costs, when screening for which program is appropriate for the client. Families also must provide proof of these expenses. A complete documentation checklist can be found here (a print version follows the Growing Up Healthy enrollment form at the end of this chapter). Families that cannot locate specific documents should not be discouraged from applying. Facilitated enrollers will help families locate necessary documents to complete their application. A note about Child Health Plus A:
Child Health Plus A will pay for eligible children's medical bills incurred up to three months before the application. Families seeking coverage for these bills also must submit copies of the bills at the time of application!
CHOICES YOU NEED TO MAKE WHEN A CHILD ENROLLS IN MANAGED CAREChildren in Child Health Plus A have the same choices about whether to join Medicaid managed care as people who are in regular Medicaid. Children in CHP A may be required to join a managed care plan unless they are exempt or excluded. Children in Child Health Plus B must be in a managed care plan; a plan much be chosen when the child enrolls in Child Health Plus B. All Child Health Plus B managed care plans are required to offer children a standard package of benefits, but plans have different lists of doctors and hospitals that children can use. Families must choose from the plans that serve their particular borough or neighborhood. To find out what managed care plans are available for
children, call Child Health Plus B, at 1-800-698-4KIDS.
Q. What questions should be considered when choosing a Child Health Plus managed care plan?
Why is it necessary for a child to choose a "primary care provider"?
Children enrolled in any managed care program must have a primary care provider (PCP), who will keep their records, give them routine check-ups and immunizations, handle general illnesses and refer them to specialists. The PCP controls a child’s ability to go to specialists. Once a child is enrolled in a managed care plan, the family may not take a child directly to a specialist even if they think the child needs one. Families must first get a referral to a specialist from their child’s primary care provider. Some plans allow a client to have a specialist as the PCP. If the child has a chronic illness and might benefit from having a specialist be the PCP, ask the plan if they will permit the specialist to act as the PCP. Even if a family enrolls all their children in the same managed care plan, the children are permitted to have different PCP’s as long as the doctors are part of the managed care plan’s provider network. Q. What if families want to switch to another primary care provider (PCP) or a whole different managed care plan for their child? A. To change a child’s primary care provider, call his/her plans’s Member Services Department and request a new primary care provider and give the name of the new physician of choice. Unless the new doctor is unable to take on new patients, families should be able to make the switch. To switch between managed care plans for Child Health Plus A, the same rules apply to children as those applied to adults enrolled in Medicaid Managed Care(See Chapter 5A). To switch Child Health Plus B plans, an applicant needs to disenroll his or her child from the original plan and join a new plan. Families can enroll in the new plan by completing an application with a facilitated enroller at the new health plan or in the community. The facilitated enroller can help disenroll the child from the old plan so that there is no gap in coverage. Generally, if an applicant completes the new application before the 20th of the month, the child’s new enrollment will be effective the first of the next month; if it is after the twentieth, the new enrollment won’t take effect until the following month. The applicant should notify the child’s old plan’s Member Services Department of the date needed to have the child disenrolled. To avoid a gap in coverage, the family can also ask the old plan for a letter with the effective disenrollment date. Then, when enrolling the child in a new CHP B plan, the applicant can show the new plan the letter stating the child’s effective date of disenrollment from the previous plan. An example of a schedule that will ensure
no gap in the children's coverage:
A family decides to apply to a new Child Health Plus B plan for July 1 enrollment. By June 1, or not much later, the family should contact the old plan requesting to be disenrolled as of July 1. Some plans accept a request and some plans may require that the family sign a “Request for Termination” form. The family will get a letter from the first plan stating the date they will be disenrolled (July 1). As long as the family applies to the new plan, and their application—with all of the necessary documentation including the disenrollment letter—is received by the new plan by June 20, the family will be enrolled in the new plan effective July 1 with no lapse in coverage. Families are encouraged to work with a facilitated enroller to avoid a gap in coverage. Take note! If by chance there is a gap in coverage and during this time there is an unanticipated medical need- the family WILL BE RESPONSIBLE for the bill.
WHAT IS NEEDED AFTER A CHILD IS ENROLLED IN CHILD HEALTH PLUS A OR BQ. What does an individual need from the managed care plan for a child to use health services? A. Once a child is enrolled in a Child Health Plus B managed care plan, the plan should send three things:
If all three things are not received: call the plan's Member Services telephone number, which should be on any papers that were sent, or contact the neighborhood facilitated enroller who helped enroll the child in Child Health Plus.
If the number is not available, call Child Health Plus: 1-800-698-4KIDS. Ask them for the new plan's Member Services "800 number."
HOW TO SOLVE PROBLEMS IN CHILD HEALTH PLUS A OR BQ. What rights does any child have as a member of a Child Health Plus B program? A. The child’s family will receive a Member Handbook or subscriber contract from the Child Health Plus A or B managed care plan (CHP B plans must issue a subscriber contract and some may issue a member handbook), which explains the benefits and responsibilities of plan members. All members in managed care plans in New York State rights which are described in the Managed Care Bill of Rights (Appendix B). The contracts for the Child Health Plus B plans also contain many of the same protections as CHPlus A/Medicaid managed care, such as limits on how long an individual has to wait for care. Q. What can be done if there are problems with the health care a child gets under Child Health Plus A or B? A. If a family has a complaint about their child’s health care, the family can file a “grievance,” an “appeal,” or a request for a “utilization review.” The process is described in Chapter 9B, and is the same for members of commercial managed care plans filing grievances and appeals. Families should first seek to resolve any issues with their health plans. However, issues that are not resolved promptly by the health plan should be called to the attention of state officials overseeing the Child Health Plus program. These officials can be reached by calling or writing:
SERVICES AVAILABLE FOR TEENAGERS IN CHILD HEALTH PLUSQ. What services do Child Health Plus A and B offer to teens? A. Both Child Health Plus A and Child Health Plus B cover many services that are particularly important for teens. The complete Child Health Plus B benefit package is listed on page 2. These include:
Q. Do teenagers need special doctors? A. As children become teenagers, their needs change, and they may want to see a doctor who understands and can address these changing needs. Both Child Health Plus A and Child Health Plus B have doctors and adolescent health centers that specialize in caring for teens (though some may be listed as pediatricians). Teens can choose different primary care providers from those used by their younger brothers and sisters. Q. Are doctors allowed—or permitted—to preserve the confidentiality of teenage patients, even from their parents? A. Generally, teens have the right to expect most services and conversations with their doctor to be kept confidential. Confidentiality applies to all conversations regarding family planning, substance abuse, and testing and treatment for HIV infection and sexually transmitted diseases (STDs). Teens have a right to receive these services without their parents’ consent. But it is important to be aware that individual providers may not follow the law and may have different policies about confidentiality. Also, some doctors and managed care plans send detailed notices and bills for treatment directly to the patient’s home. Teens should ask about these issues before choosing a doctor, so they will know what to expect. Q. Can a teenager or minor apply for Child Health Plus A or Child Health Plus B on their own? A. Sometimes. Teens can apply for Child Health Plus A (formerly Children’s Medicaid) and Child Health Plus B (and minors under age 21 can apply for regular Medicaid) on their own if they fit any one of these categories:
However, teens that live with their parents and are not pregnant will need to provide information about their parent’s income, which will be considered when determining eligibility. All teens who do not live with their parents or step-parents and all pregnant teens (whether living with their parents or not) may apply on their own, and their parents income will not be considered when determining eligibility. Q. How can teenagers receive family planning services with Child Health Plus A? A. The Child Health Plus A program offers teenagers “free access” to family planning services. This means teens can go to a provider of their choice, in or out of their health plan’s network, and receive services such as contraceptives, abortions, and STD/HIV testing and treatments. Prenatal, labor and delivery care are not included. Q. How can teenagers receive family planning services with Child Health Plus B? A. The Child Health Plus B program offers teens many important family planning services, including contraceptive medications and devices and abortions. Child Health Plus B plans should give a list of providers that offer family planning services. In addition, teenage women—like other women—can receive women’s health services (OB/GYN) without a referral from their primary care provider. This is known as “direct access.” Unlike Child Health Plus A, however, Child Health B requires the provider to be a part of their health plan’s provider network. Q. What is the Family Planning Benefit Program (FPBP)? A. The Family Planning Benefit Program (FBFP) provides family planning services for men and women of childbearing age with net income up to 200% of the federal poverty level. Adolescents up to age 21 who live at home with their parents can apply for the FBFP on their own behalf, and their eligibility will be based on their own income. Documentation requirements are the same as those for Child Health Plus A and B, and there is no resource test. To apply, use the “Access NY Healthcare” application (see Chapter 11), or a one-page application available from Medicaid offices and family planning providers. Like Child Health Plus A and B, renewal enrollment in FPBP is year.
WHAT
IMMIGRANTS NEED TO KNOW ABOUT
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| Child Health Plus B Benefits | Services that are NOT Covered by Child Health Plus B |
| Check-ups Immunizations Inpatient hospital care (365 days each year) Inpatient care for mental health, alcoholism, and/or substance abuse (30 days combined total each year) Diagnosis of treatment of illness and injury Office and clinic visits Outpatient surgery X-rays and laboratory tests Chemotherapy, hemodialysis Speech and hearing services including hearing aids Pre-surgical testing Second surgical opinion Second medical opinion on cancer diagnosis Emergency care , including emergency ground ambulance transportation including pre-hospital emergency medical services Maternity care Outpatient care for mental health, alcoholism and/or substance abuse (60 visits each year, including family therapy related to alcohol/drug abuse) Short-term physical, occupational and speech therapy Home health care in lieu of hospitalization (40 visits each year) Hospice Care Most durable medical equipment, including wheelchairs and ventilators Artificial limbs and orthotic devices Diabetic education, home visits, supplies and equipment Prescription drugs Over-the-counter drugs, if prescribed by a doctor Emergency, preventive and routine eye care, eyeglasses, and contact lenses Emergency, preventative and routine dental care, except orthodontia (braces) |
Experimental drugs, surgery or medical procedures Over-the-counter drugs not prescribed by a doctor Chiropractic care Private nurses Prescription drugs and biologicals furnished for the purpose of assisted suicide or euthanasia Home health care except as defined Nursing home care Rehabilitation care in a rehabilitation or skilled nursing facility Orthodontia (braces for teeth) Cosmetic surgery Infertility treatment Some durable medical equipment and supplies Transportation [except for emergency ground ambulance service] Personal or comfort items Services that are not medically necessary Services covered by another payment source |
Contact these agencies to enroll someone in CHP/Medicaid:
| Lead Agency | Contact Information | Proposed Service Area |
| Alianza Dominicana, Inc. | Judy Ortiz 2410 Amsterdam Ave., 1st Floor New York, NY 10033 Phone: 212-740-1960 x134 Fax: 212-740-1967 |
Upper Manhattan |
| Morris Heights Health Center | Paul Herskovitz 85 West Burnside Avenue Bronx, NY 10453 Phone: 718-483-1254 Fax: 718-483-1260 |
Bronx |
| Brooklyn Perinatal Network, Inc. | Ms. Denise West 30 Third Ave., Rm 618 Brooklyn, NY 11217 Phone: 718-643-8258 x21 Fax: 718-797-1254 |
Northern Brooklyn |
| Safe Space | Dawn Roberts-Demple 96-01 43rd Avenue, 2nd Floor Corona, NY 11368 Phone: 718-785-9050 |
Northern and Southern Queens |
| The Children's Aid Society | Lorraine Gonzalez 150 E. 45th Street, 2nd Floor New York, NY 10017 Phone: 212-503-6801 Fax: 212-681-6315 |
All Manhattan |
| Hispanic Federation | Liliana Melgar 55 Exchange Place, 5th Floor New York, NY 10005 Phone: 212-233-8955 Fax: 212-233-8996 |
Lower Manhattan and South Bronx |
| Jewish Community Center of Staten Island | Maureen Fisher 1859 Victory Boulevard Staten Island, NY 10314 Phone: 718-981-1400 Fax: 718-720-5085 |
Staten Island |
| Joseph P. Addabbo Family Health Center | Rhinda Reyes 1288 Central Ave. Far Rockaway, NY 11691 Phone: 718-868-8291 Fax: 718-868-9062 |
Far Rockaway, Queens |
| Metropolitan Council on Jewish Poverty | Lisa Gaon 80 Maiden Lane, 21st Floor New York, NY 10038 Phone: 212-453-9595 Fax: 212-453-9609 |
Southern Brooklyn |
| Ridgewood Bushwick Senior Citizens Council | Maria Viera 217 Wyckoff Ave. Brooklyn, NY 11237 Phone: 718-366-3800 x120 Fax: 718-366-8740 |
Parts of Brooklyn (Bushwick and Lower Ridgewood) |
| NYC Department of Health, Bureau of Health Insurance Services | Linda Barr-Gale and Cathy Villegas 161 William Street, 6th Floor New York, NY 10038 Phone: 212-788-5513 Fax: 212-227-7576 |
Citywide |
| Medical Health Research Association | Tali Shmulovich 220 Church Street, 5th Floor New York, NY 10013 Phone: 646-619-6400 |
Citywide |
| Union Health Center | Aisha Iturralde 275 Seventh Ave, 4th Floor Benefits Counseling Unit New York, NY 10001 Phone: 212-812-3690 Fax: 212-812-3800 |
Lower Manhattan |
| Generations Plus | Donna Sutherland Lincoln Medical & Mental Health Center Ambulatory Care Admin., 1B1 234 E. 149th Street Bronx, NY 10454 Phone: 718-579-5299 Fax: 718-579-4744 |
Manhattan and Bronx |
New York City Child Health Plus Managed Care Plans
| Managed Care Plans |
Current Service Area |
Member Services |
| A+ Health Plan | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-866-635-1519 |
| Affinity* | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-866-247-5678 |
| Americhoice of New York | Bronx, Brooklyn, Queens | 1-800-493-4647 |
| Amerigroup Community Care (formerly CarePlus) | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-800-600-4441 |
| CenterCare* | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-800-545-0571 |
| Community Choice Health Plan* | Bronx | 1-800-619-2247 |
| Community Premier Plus* | Bronx, Manhattan | 1-800-867-5885 |
| Empire Blue Cross/Blue Shield** | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-800-431-1914 |
| Fidelis Care of NY* | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-888-343-3547 |
| GHI HMO | Bronx, Brooklyn, Queens, Manhattan, Staten Island | 1-877-244-4466 |
| HealthFirst* | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-800-463-6743 |
| Health Plus* | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-800-300-8181 |
| HIP Greater NY* | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-800-447-8255 |
| MetroPlus Health Plan* | Bronx, Brooklyn, Manhattan, Queens | 1-800-303-9626 Hearing Impaired: 1-800-881-2812 |
| Neighborhood Health Providers* | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-800-826-6240 |
| NY-Presbyterian Community Health Plan, Inc. | Brooklyn, Manhattan, Queens | 1-800-261-4649 |
| United HealthCare of New York* | Bronx, Brooklyn, Manhattan, Queens, Staten Island | 1-888-396-7177 |
| WellCare of NY* | Bronx, Brooklyn, Manhattan, Queens | 1-800-215-1531 |
* Plan authorized to do facilitated enrollment
into Child Health Plus A or B
** Plan authorized to do facilitated enrollment into Child Health
Plus B only
