Monumentalidad en Lima

Child Health Plus, and Family Health Plus, 2009

400% 350% 300% 250% 200% 150% 100% 50% 0% Infants Children Age 1-5 Children Age 6-18*** Pregnant Women Parents† _Childless Adults†† Employers and Taft- Hartley Funds# % o f Fe d e ra l P o ve rt y L ev e l (F P L ) 200% 400% 400% 400% 133% 100% 100% 200% 150% 100% 85% 78% No Ceiling Legend:

* Medicaid and Child Health Plus A eligibility are expressed in net income while Child Health Plus B and Family Health Plus eligibility are expressed in gross income, as written in HCRA 2000 and Medicaid law. The 2009 Federal Poverty Level (FPL) is $10,830 for an individual and $18,310 for a family of three.

** Children with gross family income above 160% FPL are charged an income-related premium. Premiums below refer to gross family income: $9/month/child (up to $27) for those between 160-222% FPL, $15/month/child (up to $45) for those between 223-250% FPL; effective July 2009, premiums are $30/month/child (up to $90) for those between 251-300% FPL, $45/month/child (up to $135) for those between 301-350% FPL, and $60/month/child (up to $180) for those between 351-400% FPL. With some exceptions, children in families with income above 250% FPL who lose employer-sponsored coverage are subject to a six-month waiting period.

*** Effective April 2010, all children ages 1-18 will be eligible for Medicaid up to 133% FPL (net income).

† “Parent” is defined as a parent of a child under 21 years who lives in the household. Medicaid eligibility includes disabled adults and 19- and 20- year-olds up to 85% FPL. FHP eligibility includes 19- and 20-year-olds living with their parents up to 150% FPL.

†† “Childless adult” is defined as a non-disabled adult aged 21 years and over who does not have a child living in the household. FHP eligibility includes 19- and 20-year-olds not living with their parents up to 100% FPL. Effective April 2010, all 19- and 20-year-olds will be eligible for Medicaid up to 100% FPL (gross income) and for FHP up to 160% FPL (gross income). Childless couples are eligible for Medicaid up to 73% FPL, while single adults (household of one) are eligible for Medicaid up to 78% FPL.

# Employers and Taft-Hartley Funds (THF) may buy in to FHP. Employers/THF must contribute at least 70% of the premium and employees will pay the balance (the State will pay the employee’s share for MA/FHP/CHP eligibles). If an employer/THF does not currently offer coverage or is in jeopardy of discontinuing coverage (as determined by the Commissioner), the State may subsidize the employer/THF share of the premium for MA/FHP/CHP eligibles (subject to federal approval and funds appropriated).

Note:

Low-income, uninsured women who are diagnosed with breast or cervical cancer through screenings in New York’s Healthy Women Partnerships program are eligible for Medicaid coverage. Women must have income levels below 250% FPL to qualify for the screenings. Females and males of childbearing age with income up to 200% FPL are eligible for Medicaid Family Planning Services. As of July 2003, disabled workers aged 16-64 with net income of up to 250% FPL and non-exempt resources up to $10,000 are eligible for Medicaid coverage through the Medicaid Buy-In for Working People with Disabilities program (MBIWPD); enrollees with incomes above 150% FPL will eventually be subject to an income-related premium.

Family Health Plus Buy-In Family Health Plus

Prenatal Care Assistance Program Child Health Plus B**

Child Health Plus A Medicaid

and insurance holding companies (e.g., UnitedHealth Group) that own both types of licensees participate in New York’s public insurance programs. Overall, commercial HMOs insured almost one-third of persons covered under the programs, and for-profit plans — including commercial health plans and for-profit PHSPs such as AmeriChoice, WellCare, and Amerigroup — enrolled a little over 20 percent of members (Table 20).

Rebounding from the exodus that occurred in the late 1990s due to their dissatisfaction with the rate-setting scheme, commercial health plans are experiencing a pickup in enrollment, which is helping to offset declines in employer-sponsored and individual coverage. For commercial HMOs, enrollment in MMC, CHP, and FHP made up 12.8, 3.9, and 3.5 percent, respectively, of their combined lines of business. As a senior official from an upstate health plan noted, “Commercial business is leaking, but safety net business is up.”

Regional enrollment patterns for public programs are something of a “through the looking glass” version of commercial enroll- ment patterns. While upstate commercial markets are dominated by nonprofit health plans, upstate regional public markets — with the exception of the Syracuse area, in which Fidelis and Total Care dominate — are largely “PHSP-free zones.” Enrollment is concentrated in one or two commercial HMOs, such as CDPHP, MVP/Preferred Care, or PHSPs sponsored by commercial health plans including Univera, part of the Excellus family.

And just as a handful of major commercial health plans square off in the downstate commercial market, a handful of muscular PHSPs compete head-to-head in the New York City public markets, where only commercial health plans HIP and the UnitedHealthcare/ AmeriChoice combination are strong.

As is the case with the commercial markets, there is not a single health plan

with a real statewide reach in all public markets. PHSP Fidelis is a top-tier health plan in New York City, its suburban counties, and throughout most of upstate, but has no presence in the Rochester region. Excellus, with its broad geographic sweep and strong partners in the Monroe County Health Plan and Univera PHSP, lacks access to the downstate market where public program eligibility is concentrated. UnitedHealthcare/ AmeriChoice has a strong base in New York City and is expanding its reach in upstate public program markets.

Rates

To some degree, rate-setting rules for public programs resemble those in effect for commercial health plans prior to rate deregulation, although new changes are being phased in. Until recently, health plans submitted rate increase requests to the Department of Health for Medicaid Managed Care and Family Health Plus based on their own claims experience, expenses, and projections of medical trend. Within state funds appropriated for the programs and based on the state’s overall projection of medical costs, rates were approved for each plan for a number of “rate cells” or categories of enrollees, broken down by demographics, aid categories (e.g., Temporary Assistance for Needy Families vs. SSI), and region. Health plans also compete for bonuses based on performance in quality measures selected by the Department of Health.

State rules cap health plan administrative expenses and, from time to time, state budget exigencies have resulted in arbitrary cuts in health plan reimbursement. So far the rate cuts, most recently in the fall of 2008, haven’t resulted in health plan withdrawals from the programs, and PHSPs, which may not participate significantly in commercial markets, represent a captive audience.

Article 44 HMOs Medicaid Child Family Total

Health Plus Health Plus

AmeriChoice 94,265 1,333 15,466 111,064

CDPHP 35,548 18,425 6,665 60,638

Community Blue/HealthNow New York 30,189 13,978 7,819 51,986 Excellus Health Plan HMO 64,263 45,285 17,772 127,320

GHI HMO 13,124 2,969 6,526 22,619

HIP 189,331 3,218 51,058 253,607

Independent Health Association 25,150 25,150

Managed Health Inc. 2,273 2,273

MVP Health Care 3,347 1,545 1,365 6,257

Preferred Care 17,578 17,578

UnitedHealthcare of New York 63,610 2,180 25,596 91,386 WellCare of New York 61,204 12,744 29,68 103,628

Subtotal 599,882 111,677 161,947 873,506 Percentage of Enrollment by Program 30.4% 34.5% 32.6% 31.3%

Prepaid Health Services Plans Medicaid Child Family Total

Health Plus Health Plus

Affinity Health Plan 134,408 28,577 43,244 206,229 Amerigroup 79,047 17,907 29,106 126,060 Centercare 55,471 4,117 10,010 69,598 Community Choice Health Plan 10,750 3,666 1,943 16,359 Community Premier Plus 64,724 3,021 8,550 76,295 HealthFirst PHSP 268,765 29,562 69,429 367,756 HealthPlus 186,918 24,951 44,286 256,155 Hudson Health Plan 34,677 19,354 7,472 61,503 MetroPlus Health Plan 186,902 18,432 37,451 242,785 Neighborhood Health 75,412 8,058 16,616 100,086 NewYork-Presbyterian 5,990 3,492 11,398 60,880 NYS Catholic Health Plan (Fidelis Care) 184,973 37,313 42,911 265,197 Suffolk County 10,786 3,817 72 10,786 Total Care

(Syracuse Community Health Center) 18,450 3,284 3,302 25,036 Univera Community Health 17,441 6,201 9,425 33,067

Subtotal 1,374,714 211,752 335,215 1,917,792 Percentage of Enrollment by Program 69.6% 65.5% 67.4% 68.7%

TOTAL 1,974,596 323,429 497,162 2,791,298