Recent Changes to Medicaid Eligibility

December 1, 2008

Author: Trilby de Jung

Governor Paterson seems to understand that in these hard economic times, access to public health insurance is more important than ever.  This year’s budget contains proposals to increase access by eliminating administrative barriers in Medicaid like fingerprinting and the asset test.  It also proposes raising income levels in the Family Health Plus program to 200% of the federal poverty level.  These proposals are part of a trend that started when Eliot Spitzer took office.  New York has expanded eligibility for Medicaid and related programs significantly over the last several years.

This article will summarize legislative changes to Medicaid eligibility enacted over the last two legislative sessions.  As economic pressures mount for state and local government, it is more important than ever for advocates to monitor eligibility determinations to ensure that recent changes in the law are honored at the local district level.  After all, implementation always lags behind legislative change.

1.     Higher (and Standardized) Income levels for Single Adults and Childless Couples 

Effective April 1, 2008, single adults and childless couples applying for Medicaid will be governed by the same income test,  regardless of their county of residence.  Legislation passed in the 2008 Budget uses the Nassau County standard of need to calculate budgets for all applicants in this category, resulting in a monthly income eligibility level of $673 for one person households and $840 for households of two.  N.Y. Soc. Serv. L. §366(1)(a)(1),(8) as amended by L. 2008, c. 58.    See also; GIS 08 MA/022.

2.     Higher Income Levels for Medicaid’s Medically Needy Program

The income levels for single adults and couples applying for the Medically Needy or Spend Down program had been frozen in 2005 and 2006, which meant SSI-related individuals and couples were subjected to lower income levels than those receiving SSI.  A class action lawsuit challenging this inequity was filed in Rochester in December of 2005. Blair v. Novello, Index No. 15486-06.  

In 2007, following negotiations in Blair, the law was amended to authorize medically needy income levels for all applicants at the same amount specified for SSI recipients.  See N.Y. Soc. Serv. L. §366(2)(a)(7) as amended by L. 2007, c. 58.  However, the increased eligibility was conditioned on federal approval, which has not been issued to date.

Following further negotiations in the Blair case, state law was changed again to remove the federal funding contingency.  N.Y. Soc. Serv. L. §366(2)(a)(7) as amended by L. 2008, c. 58.  Finally, effective January 1, 2008, the medically needy income levels were raised to match the income level specified for the SSI program in New York:  $725 in monthly income for one person and $1067 for couples, with increments of over $100 monthly for subsequent household sizes (see income chart attached to GIS 08 MA/022) from DOH website http://www.health.state.ny.us/health_care/medicaid/reference/mrg/july2008/page534_536.pdf.)

3.     CHP Expansion to 400% of FPL

In 2007 the Legislature approved expansion of New York’s CHP program from 250% of the    federal poverty level to 400% of the poverty level.  The 2007 budget language made this   expansion contingent upon federal approval, which was denied.  N.Y. Pub. Health L. §2511, as amended by L. 2007, c. 451.

In 2008, the legislature removed the contingency language, approving the CHP expansion to 400% of poverty with state only dollars.  The new levels will become effective on September 1, 2008.  N.Y. Pub. Health L. §2511, as amended by L. 2008, c. 58.

Most children in the expansion group (incomes between 250 and 400% of poverty) who lose employer related health coverage are subjected to a six month waiting period before then can enroll in CHP.  Exceptions include:

• Children under the age of five
• Children for whom employer coverage cost more than 5% of the family’s income
• Children who lost coverage when COBRA expired

4.     Significant increase in Medicaid’s Asset Levels

Effective April 1, 2008, asset levels for all applicants to Medicaid, including single adults and childless couples, were raised to the same asset level allowed for applicants to the FHPlus program.  Households of one can now have $13,050 in savings and still qualify for Medicaid.  The new asset level for households of two is $19,200.  N.Y. Soc. Serv. L. §366(2)(a)(4) as amended by L. 2008, c. 58.  See also GIS 08 MA/013.

5.     Elimination of the Asset Test for the Medicare Savings Programs

Effective April 1, 2008, the asset test was removed from the Qualified Medicare Beneficiary program (QMB) and the Specified Low Income Medicare Beneficiary (SLMB) program.  The Qualified Individuals-1 (QI-1) program already disregards resources.  See N.Y. Soc. Serv. L. 367-a(3)(a)(d), as amended by L. 2008, c. 58.

In addition, the face to face interview requirement was eliminated from the MSP programs, effective April 1, 2008.  A new application form for the MSP programs is available as an attachment to the Administrative Directive explaining the changes to the programs.  See GIS 08 MA/016.

6.     Self-declaration of Income at Renewal. 

Effective January 1, 2008, local social service districts must allow Medicaid recipients who are not seeking long term care, and all FHPlus recipients, to self-attest to the amount of their income at renewal.  N.Y. Soc. Serv. L. §§ 366-a(5)(d) & (e), 369-ee(2)(d) as amended by L. 2008, c. 58.

The same goes for recipients of Medicare Savings Programs, the Family Planning Benefit Program, and the Medicaid Buy-In Program for Working People with Disabilities, and the Medicaid Cancer Treatment Program – as long as recipients are not seeking coverage for long term care.

The exception is recipients who qualify for Medicaid through the Spend Down program.  These recipients will still need to document the level of their income at renewal.

Local social services districts are directed to verify the accuracy of the income recipients attest to by comparing it to information which they already have access to, such as the RFI (Resource File Integration), a currently stored budget, or documentation in a current Food Stamp or HEAP case. 

If a discrepancy is found, and use of the level of income found in existing files would result in ineligibility for a program, the local district is instructed to provide at least ten days notice to the recipient, giving the recipient the opportunity to supply documentation of the lower income level.  See 08 OHIP/ADM-4.

7.     Self-declaration of Residence at Renewal

Also effective January 1, 2008, the same group of Medicaid recipients must be allowed to self-attest to their residence, even if it has changed since the time of application.  N.Y. Soc. Serv. L. §§ 366-a(5)(d) & (e), 369-ee(2)(d) as amended by L. 2008, c. 58;  08 OHIP/ADM-4

8.     Self-declaration of Child and/or Adult Care Expenses at Renewal

Also effective January 1, 2008, the same group of Medicaid recipients will no longer need to document their child/adult care expenses at renewal.  N.Y. Soc. Serv. L. §§ 366-a(5)(d) & (e), 369-ee(2)(d) as amended by L. 2008, c. 58;  08 OHIP/ADM-4.

9.     Drug & Alcohol Screening & Treatment Sanctions Eliminated

Drug/Alcohol Sanctions Eliminated -- As a throw-back to Medicaid’s original ties to New York’s cash assistance programs, single adults and childless couples have historically been subject to Medicaid sanctions (loss of Medicaid eligibility) for non-compliance with drug and alcohol screening and treatment. 

Effective April 1, 2008, drug/alcohol screenings and treatment is no longer a condition of Medicaid eligibility for any applicants or recipients, including single adults and childless couples.  N.Y. Soc. Serv. L. §366(1)(a)(1),(8) as amended by L. 2008, c. 58.

10.    Transfer Sanctions for Community Medicaid Eliminated

Single adults and childless couples have also been subjected to sanctions or penalties for transfers of assets for less than fair market value.  Even when applying for community Medicaid as opposed to long term care, single adults and childless couples were ineligible for Medicaid for one year following the date of the transfer of assets for less than fair market value during the 12 month period leading up to the Medicaid application date. 

Effective April 1, 2008, single adults and childless couples are no longer subjected to transfer penalties when applying for community Medicaid.  N.Y. Soc. Serv. L. §366(1)(a)(1),(8) as amended by L. 2008, c. 58.  Single and childless couples are still subject to the same transfer penalties that apply to all those who apply for Medicaid coverage for long term care services.

11.    Continuity of Medicaid Coverage for County to County Moves

This issue has long plagued Medicaid recipients who move from one county to another in New York.  New counties of residence have often required new Medicaid applications, even when eligibility status has not changed. 

Legislation passed in 2008 finally provides continuity of coverage for Medicaid recipients moving inter-district, as long as they have informed the original district of residence of their new address and any material changes in circumstances affecting Medicaid eligibility.   The case must be transitioned to the new district without requiring termination in the old district or a new application in the new district.  N.Y. Soc. Serv. L. §62(5)(a)(a-1) as amended by L. 2008, c. 58 (effective June 1, 2008).  

This change in law was required as a result of federal litigation filed in the Eastern District in 2005.  See, Luberto v. Daines, Index No. CV-05-5421 (EDNY).   The consent decree negotiated in Luberto applies the new policy to recipients who notify local districts of moves on or after December 28, 2007.  See LCM 08 OHIP/LCM-1.  

Neither the new law nor the consent decree apply to institutionalized individuals who move to a different facility.  A recent administrative directive (08 OHIP/ADM–5) establishes that the new county will be the district of fiscal responsibility for SSI recipients who move from one county to an institution or group home in another, but we can still expect glitches in transferring Medicaid for these clients.  Problems have also arisen in implementing the new policy for recipients of home care and transportation services.  If your clients run into any of issues related to inter-district moves, please contact counsel on Luberto, Peter Volmer, at pvollmer96@aol.com.