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Family Health Plus Premium Assistance Program

The Family Health Plus Premium Assistance Program ("FHP-PAP") was established in 2007 to help low-income workers who are eligible for the regular Family Health Plus Program ("FHP") to access insurance offered by their employers, and to help the state recognize the savings that could be achieved by maximizing use of private, employer sponsored insurance coverage. 

FHP-PAP is codified at NY SSL ยง369-ee (3-a), which provides that persons who meet the eligibility requirements for FHP cannot enroll in, or must disenroll from, FHP  -- if a determination is made that they have access to cost-effective employer sponsored insurance.  Once the cost-effective determination is made, the new law requires that such individuals enroll in the employer sponsored insurance in order to receive or continue to receive health care services under the FHP program.

Implementation of FHP-PAP has been challenging for counties.  Although FHP-PAP has the potential to be an important bridge between public health insurance and employer sponsored coverage, advocacy may be needed to help clients who try to apply for FHP and encounter the availability of employer sponsored insurance in their workplace as a bar. 

How FHP-PAP Should Work

The steps that are required for enrollment in the program are spelled out in OHIP 08 AMD-1, which was issued in January of 2008.  Local social services districts enountered such confusion with the program that the State Department of Health issued an informational letter, 08 OHIP/INF-6. consisting of Frequently Asked Questions about the FHP-PAP program. 

At application and renewal, districts and facilitiated enrollers are instructed to ask FHP eligible individuals about whether they have access to employer sponsored health insurance.  Individuals are considered to have access if they are eligible for the coverage by the employer's rules and have the ability to enroll (process is reasonable and uncomplicated). 

If the individual answers "yes" - district workers should explain the requirement to enroll in qualified, cost effective employer sponsored insurance.  The applicant will be asked to fill out an Employer Sponsored Health Insurance Form (Attachment C to OHIP 08 AMD-1).  The district will then make a determination as to whether the coverage is qualified and cost effective.  Pending a final determination as to these questions, the individual should be enrolled, or continue to be enrolled, in a FHP plan.

Employer sponsored insurance will be considered qualified if it includes, at a minimum, inpatient and outpatient hospital services, physician services, maternity care, preventive health services, diagnostic and x-rayservices, and mergency services.  The plan does not have to include prescription drug benefits.

Cost effectiveness is a more complicated determination.  Districts are instructed to perform this calculation using a tool that has been developed specifially for FHP-PAP.  Medicaid eligible children are included in the calculation.  If the district determined that a family premium is not cost-effective, it will then do a cost effectiveness determination just for the parents, if the premium is different for the parents alone.

Non-Medicaid eligible chilren over the age of 6 are not included in the calculation.  For these children, if the family premium is determined cost-effective, the parents are expected to pay the children's deductibles and co-pays and are not reimbursed for any costs associated with the non-Medicaid elibgible children.   The family should still have the choice of enrolling the children in CHP rather than the employer sponsored coverage, although the district will encourage the family to enroll the children in the employer sponsored coverage. 

If the coverage is not deemed qualified and cost effective applicants remain in regular FHP.  If the coverage is deemed qualified and cost effective, the individual is enrolled in the employer sponsored product and disenrolled from the FHP plan at the earliet opportunity under the employer's requirements for participation.  The applicant should not be forced to disenroll from FHP until he or she can enroll in the employer sponsored plan.

The FHP-PAP program will then pay the portion of the premium for the employer sponsored insurance that is not paid by the employer.  Districts are instructed to pay the insurance plans directly where possible, and make preimum payments directly to the enrollee when necessary.  FHP-PAP should also pay claims for deductibles, coinsurance and co-payments, according to the co-payment schedule established for regular FHP.  The co-pay schedule and exemptions to co-pay requirements in the FHP program are included in the FHP-PAP FAQ issued under 08 OHIP/INF-6Enrollees have to pay the co-payments, coinsurance and deductibles initially, and then bring the receipts into the district for reimbursement. 

Enrollees in FHP-PAP are also entitled to the services that FHP covers but are not covered by the employer sponsored health insurance plan -- including dental services and prescription drugs.  These services are referred to as "wrap around benefits."    Enrollees should use their New York State Benefit Identification card to pay for wrap around benefits as these services are billed on a fee for service basis.  Enrollees are required to go to a Medicaid provider for wrap around services.  However, districts do have the ability to reimburse enrollees who visit non-Medicaid providers when no Medicaid provider is available. 

Transitions from FHP to FHP-PAP, and from FHP-PAP back to FHP when an enrollee loses employer sponsored coverage, require communication between districts, managed care plans and employers.  Systems implications are complicated.  Although districts are instructed that they must avoid gaps in coverage, clients will undoubtedly need help navigating the system and may need advocacy services in order to assure assistance with all premiums and payment on all health care bills. 

This article was authored by the Empire Justice Center.

Empire Justice Center

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