Resources for Uninsured and Underinsured

This article briefly explains how uninsured people -- those without Medicare, Medicaid, or private health insurance -- may obtain help with hospital, prescription drug and other medical bills. First is a brief explanation of New York's Hospital Financial Assistance or Charity Care law, with a longer article at this link. Second are explanations of certain targeted insurance programs for special populations, with links to more information. Third is information about sliding-scale services provided by New York City public hospitals and clinics.

Starting JAN. 1, 2024 - Undocumented Immigrants age 65+ can get FULL MEDICAID

All immigrants age 65+ can qualify for Medicaidd even if they do not qualify for PRUCOL status. See this official Fact Sheet that explains how immigrants age 65+ can access full Medicaid - New Health Insurance Option for Undocumented Immigrants Over 65 Fact Sheet (Dec. 18, 2023 -NYS of Health). See more here. This was postponed from January 2023.

Essential Plan (EP) -

NYS's program that exercises an option under the Affordable Care Act to establish a "Basic Health Program). 42 U.S.C. 18051, 45 C.F.R. 156.420. These programs are for people under 65 with income above the Medicaid limit. Originally the income limit was 200% FPL and will be going up to 250% FPL in 2024. The EP is designed to reduce health care costs for lower income people for whom enrolling in a Qualifed Health Plan on the NYS of Health would be expensive.

Also the EP allows NYS to obtain a federal subsidy to provide health care to legal immigrants who are "PRUCOL" - many PRUCOL immigrants switch from Medicaid to the Essential Plan because it is partly federally funded. See this article about PRUCOL Medicaid.

Federal law requires BHPs to cover "essential health benefits." 42 USC 18022.

Essential Plan: NY Soc. Serv. L. Sec. 369-gg

See NYSofHealth Info about the Essential Plan.

Patient Access to Hospital Charity Care Funds - NYS Hospital Financial Assistance Law

Effective January 1, 2007, all general hospitals must establish written policies and procedures for the provision of financial assistance to reduce the hospital bills of low income New Yorkers who are uninsured or underinsured.

The patient financial assistance section in New York’s Charity Care law establishes a sliding fee scale rate for all patients living at or below 300% of the federal poverty level. Under this provision hospitals cannot charge more than $150 to patients with incomes at or below the FPL and charges for patients with income up to 300% of the FPL cannot exceed the Medicaid rate for services received. N.Y. Pub. Health L. § 2807-k(9-a).

In addition to limiting charges, the patient financial assistance law requires the following:

Hospitals must establish financial assistance policies and procedures which include the above sliding fee scale limits on charges, contain specific application and appeal processes and provide for the training and supervision of staff to implement the policy.
Hospitals must provide notice of the existence of financial assistance policy and applications through signage upon intake and on bills in language appropriate manner.
Notice of the hospital’s financial assistance policy and applications must be provided in languages spoken during more than 5% of hospital visits or by non-English speaking individuals comprising more than 1% of the population in the hospital’s service area.
Applicants must be provided with a financial assistance application, upon request within 90 days of the date of service or discharge and must be given 20 days to complete the application. Hospitals can require that patients apply for public health insurance as a condition of eligibility for financial assistance.
Decisions on financial assistance applications must be made within 30 days of the complete application and must notify patients of appeal rights.
Hospitals may take no action to collect on bills until the financial assistance application is processed in accordance with the hospitals’ financial assistance policy.
Installment payment plans are required and cannot exceed 10% of the patient’s gross monthly income. Under special circumstances a patient’s assets may be considered, with the exception of a primary residence, retirement plans, college savings accounts and a vehicle.
Acceleration clauses on installment payment plans are prohibited, and non-emergency care deposits must be made in accordance with the financial assistance policy.

SDOH has posted the requirements of the law and information on hospitals on its New York State Hospital Profile webpage.

See more in this article on this website.

Targeted Insurance Programs

Elderly Pharmaceutical Insurance Coverage (EPIC) Program

EPIC is a prescription drug benefit plan for New York residents who are over the age 65. The EPIC program has modest co-pays. A single person must have income less than $75,000 a year to qualify. Couples must have income less than $100,000. See our article about EPIC and how it works with Medicare Part D and other information. To get an application or ask questions about EPIC, call 1-800-332-3742 or visit their website at http://www.health.state.ny.us/nysdoh/epic/faq.htm.

Prescription Drug Discount Cards and Patient Assistance Programs

These are options to assist with the cost of prescription drugs for those without insurance, or who are under-insured. See more in our article that focuses on these programs.

AIDS Drug Assistance Program (ADAP)

ADAP has four programs for uninsured or underinsured persons living with HIV:

New York’s regular ADAP program, which provides access to a comprehensive formulary of drugs for uninsured or underinsured persons with HIV infection.
The ADAP Plus program, which covers primary care, including early intervention and ongoing treatment for HIV disease.
The HIV Home Care program.
The ADAP Plus Insurance Continuation program (APIC), which pays for commercial health insurance premiums for ADAP-eligible clients who have existing private coverage.

To be eligible for ADAP, the household income must be at or below 435% FPL - see limits here. The resource limit for all households is $25,000.

Medicaid Cancer Treatment Programs (MCTP)

MCTP expands Medicaid eligibility for individuals diagnosed with breast, cervical, colorectal and prostate cancer or with precancerous conditions. Individuals must enroll through designated entities called Cancer Services Program Partnerships, which are listed by county on the DOH website. Applicants should call their local center and make an appointment for an interview and to fill out an application, which is then processed centrally by SDOH. The income limit for the program is 250% of poverty and there is no resource limit. Applicants cannot have any other insurance coverage. All other Medicaid eligibility requirements apply. Eligibility for the breast and cervical cancer programs is limited to those 18 years of age or older; eligibility for the prostate and colorectal programs is limited to those under 65. Individuals enrolled in the program have full Medicaid eligibility; their coverage is not limited to cancer care. Applicants do not have to have a new diagnosis of cancer in order to get care, even if they have already received treatment, as long as they do not currently have creditable insurance coverage and meet the other eligibility requirements. More information about the program is available at http://www.health.state.ny.us/nysdoh/bcctp/bcctp.htm.

Public Hospitals and Clinics – New York City

Public hospitals and community based clinics often provide discounted or free medical care and medication. Many of these providers treat uninsured individuals for free or at a reduced rate, called a sliding fee scale. In New York City, the public hospital system is run by the New York City Health + Hospitals Corporation (H+H ). There are H+H facilities throughout the city.

HHC offers a sliding fee scale program for uninsured and underinsured patients called NYC Care. This program offers reduced fees for in-patient and out-patient services. The sliding fee scale is at this link https://www.nychealthandhospitals.org/financial-assistance/ (scroll down to WHAT DO I PAY? Heading). The fee scale is also on PAGE 12 of the new member handbook.

HHC also has a Home Care Agency which should provide home care to the uninsured, including undocumented immigrants. See information on NYS DOH website here. Note that in January 2023, undocumented immigrants age 65 and over will be eligible for full Medicaid. Stay tuned about news here.

This article was authored by the Health Law Unit of the Legal Aid Society.