Last Updated: January 2005

GOVERNMENT PROGRAMS FOR WHICH YOU MAY BE ELIGIBLE

Q. What low-cost and free government programs are available, but under-utilized, because people don't know these programs are available?

A. There are many special free or low-cost health coverage programs that may be hard to find out about. The major programs like this are Medicaid, Veterans Benefits, Child Health Plus, Family Health Plus, and Healthy New York.

Q. Who is eligible for health insurance coverage under the Medicaid program?

A. Many people are eligible for coverage but do not know it. Most hospitals will apply for coverage for you if you are admitted, or will help you to apply before or after they treat you in a clinic. Medicaid is available for:

• People who left welfare to go to work, but don’t have insurance at their new job, for the first year after they leave welfare.
• People who lose welfare payments because of some problem with the welfare rules, if the problem is not related to their income level.
• Working people who meet the income, resource limits and other Criteria of Medicaid
• Low-income people on Medicare (Dual-Eligible).
• Qualified aliens who entered the country prior to August 22, 1996.
• Pregnant women and children whose income is too high to be eligible for welfare payments.

See Chapter 5A for details on the Medicaid program.

Q. What is the Prenatal Care Assistance Program (PCAP)? 

A. PCAP is a comprehensive prenatal care program that offers complete pregnancy care and other health services to women and teens who live in New York State and meet certain income guidelines. (Women are eligible for services up to 200% of the federal poverty level.) PCAP offers routine pregnancy check ups, hospital care during pregnancy and delivery, full health care for the woman until at least two months after delivery and full health care coverage for the baby up to one year of age.

PCAP has several advantages over regular Medicaid prenatal programs:

• PCAP staff are stationed in certain clinics where you can get a pregnancy test or prenatal care. PCAP staff will complete the application form for you, conduct your Medicaid interview at the clinic where you sign up, bring your application and supporting documents to the Medicaid office, and advocate on your behalf at the Medicaid office when necessary.
• Once you complete your application, the Medicaid office will decide whether you appear to be eligible. If you do, a “presumptive period” will start, during which you will be covered by Medicaid until the Medicaid office makes a final decision on your eligibility.
• You do not have to provide proof of U.S. citizenship or residency to apply for PCAP.
• You can qualify for PCAP coverage if your income is up to 200% of the federal poverty level.
• Doctors and clinics who participate in PCAP must offer a comprehensive medical services package, including diagnostic and treatment services, psychosocial assessment, nutrition, health education, HIV counseling and testing, and other more

Call 1-800-522-5006 for more information about the PCAP program.

Q. What if my income is a little too high for me to qualify for PCAP?

A. Some PCAP providers choose to offer the same benefit package on a sliding-fee scale to low-income women who are unable to afford insurance or private care, even though their income is too high for PCAP.

Q. What kind of health care can the Veteran's Administration provide for veterans?

A. Men and women who were in the armed forces can get medical care from the Veterans Administration. See Chapter 8 for more details. 

Q. What is Child Health Plus and who can use it?

A. Child Health Plus B provides free or low-cost health coverage for children who are not eligible for Medicaid until they reach the age of 19. The cost of coverage starts at zero for families with the lowest incomes. The cost goes up on a sliding scale, so it is higher for families with more income, but it is still less than buying insurance on your own.
(See Chapter 7 for more details.)

Q. What is Family Health Plus and who can use it?

A. Family Health Plus provides free health coverage for New York State adults between the ages of 19 and 64 who are not eligible for Medicaid and:

• Have dependent children and earn up to 133% of the poverty level during the program’s first year, and 150% during its second year
• Have no dependent children and earn up to 100% of the poverty level
• Meet Medicaid’s definition of a “qualified immigrant”
• Have no other health insurance

Family Health Plus provides comprehensive coverage through the same Health Maintenance Organizations that are available to children under Child Health Plus. See Chapter 11 for more information about Family Health Plus.

Q. What is Healthy NY and who can use it?

A. Healthy NY is a standardized health insurance benefit package offered at a discounted rate by all health maintenance organizations (HMOs) in New York State. This discounted version of insurance is only available to certain small employers (for their employees and employees’ families), sole proprietors, unemployed individuals, and uninsured working individuals. Each group has its own set of eligibility criteria and participation rules.

Q. What is included in the standard Healthy NY benefits package? ?

A. Healthy NY benefits cover inpatient and outpatient hospital services, physician services, maternity care, preventive health services, diagnostic and x-ray services, emergency services, and some prescription costs. You can only receive care and prescriptions from the HMO’s network of providers, except for emergency services or types of care not available through the HMO’s providers.

• Inpatient hospital services (room and board, general nursing care, special diets, miscellaneous hospital services and supplies)
• Pre-admission testing
• Maternity care
• Outpatient hospital services consisting of diagnostic and treatment services
• Outpatient surgical facility charges related to a covered surgical procedure
• Emergency services
• Physician services (diagnosis and treatment, consultant and referral services, surgery--including breast reconstruction surgery after a mastectomy, anesthesia services, and second opinion for surgery and cancer treatment)
• Adult preventive services (mammography, Pap smear, physical examinations once every three years, and adult immunizations)
• Preventive and primary health care services for dependent children including routine well-child visits and necessary immunizations
• Equipment, supplies and self-management education for the treatment of diabetes
• Diagnostic x-ray and laboratory services
• Therapeutic services consisting of radiological services, chemotherapy and hemodialysis
• Blood and blood products furnished in connection with surgery or inpatient hospital services
• Prescription drugs obtained at a participating pharmacy ($3,000 maximum per person, per year) only if the drug benefit is selected.

Q. Is there a charge for Healthy NY coverage? 

A. Yes, there are premiums, copayments, and a prescription deductible.

Premiums: You must pay a monthly premium for Healthy NY, and premiums are different based on which HMO you choose. For assistance in comparing HMOs, call the NYS Insurance Department's Resource Center at 1-800-342-3736 and ask for a copy of the New York Consumer Guide to HMOs. You may also use the guide online, at www.ins.state.ny.us.

Prescription deductible: you must pay an “annual deductible” for prescriptions, meaning that every year, you must pay the first $100 of prescription expenses, before the insurance will begin to cover it. All HMOs require this deductible, and all will charge the same amounts for copayments, following the list below:

Copayments: Usually, you must pay any copayment before services are given.

Q. What if I have a pre-existing medical condition? 

A. Coverage under the Healthy NY program for pre-existing conditionsmay be subject to up to a one year waiting period if diagnosis or treatment occurred within the last 6 months. Before you enroll, ask the HMO how this waiting period would affect you, if you have any existing health conditions, especially ones for which you received medical care recently.

Q. How can I apply for Healthy NY coverage?

You must apply for the Healthy NY coverage directly to the HMO you have chosen. You can get an application form from the HMO, or fill out the standard application form found on the Healthy NY website, at www.ins.state.ny.us/healthny.htm. There is one application form for individuals and sole proprietors, and a different application form for small employers.

When you submit your application, if you are applying as an individual or sole proprietor, you will also be asked to provide documentation of proving your residence, household income, and employment status. Examples of acceptable forms of documentation include:

• For income: pay stubs, letter from employer, W-2 forms, tax returns
• For employment status: letter from employer, pay stubs
• For residence: utility bill, postmarked mail with your address, lease, letter or rent receipt from your landlord, with your home address

Q. What are the requirements to be eligible for Healthy NY as an individual or sole proprietor?

A. You must meet all of the requirements below:

• You do not have an employer who currently provides you with health insurance, or has provided group health insurance during the twelve months just before your application.
• Your gross household income level is at or below 250% of the gross federal poverty level, as shown below.
• You have not had health insurance for the twelve months just before your application, or you lost that coverage due to any of the following:
  • Loss of employment
  • Death of a family member
  • Change to a new employer
  • Change of residence
  • Discontinuation of a group health plan
  • Termination or cancellation of COBRA coverage
  • Legal separation, divorce or annulment
  • Loss of eligibility for group health insurance coverage
  • Reaching the maximum age for dependent coverage
• You are not eligible for Medicare.
• You must reside in NYS.
• You must be employed on a full-time, part-time or episodic basis. You will be considered employed on an "episodic" basis if you can show that you worked for some portion of twenty weeks in the last year.

Q. What are the requirements for a small employer to be eligible for Healthy New York?

A. A small employer must meet all of the requirements below:

• The employer must have 50 or fewer eligible employees
• The small employer must not have provided group health insurance coverage to their employees within the preceding twelve months
• One third of employees must earn wages of $33,000 or less, and all employees earning $33,000 or less must be offered coverage through Healthy NY.
• 50% of the eligible employees must participate in the program and at least one participant must earn annual wages of $33,000 or less
• The employer must pay at least 50% of employees’ premiums
• The business must be located within NYS
• Seasonal workers, and part-time employers working 20 or more hours weekly, can be counted as employees as long as they are offered coverage.

Q. Must my employer offer Healthy NY coverage to my family?

A. Coverage for dependents does not have to be offered, but it may be offered if the employer chooses to. Dependents include children up to age 19 and full time students up to age 23. Employers do NOT have to contribute towards the cost of dependent coverage. However, it may be less expensive for lower income employees to enroll their children in Child Health Plus, rather than Healthy NY.