Chapter 7: Child Health Insurance/Child Health Plus

Last Updated: April 2007

CHILDREN’S HEALTH INSURANCE/CHILD HEALTH PLUS 

The material in this chapter has been licensed by The Children's Defense Fund

Q. What are the New York State Children’s Health Insurance Programs?

A. Child Health Plus is New York State’s health insurance program for children under 19 who need health insurance. This program has two parts: Child Health Plus A (formerly known as Children’s Medicaid) and Child Health Plus B. Nearly all of New York State’s uninsured children are eligible for free or affordable health insurance under one of these two programs.

CHILD HEALTH PLUS A

Q. What is Child Health Plus A (formerly Children’s Medicaid)?

A. Child Health Plus A is part of the Medicaid program and follows many of the same rules as the regular Medicaid program. Child Health Plus A is a free health insurance program for lower income children up to age 19. But Child Health Plus A is different from the regular Medicaid program in two important ways:

• Child Health Plus A has more generous income guidelines than regular Medicaid: This means that many children are eligible for Child Health Plus A even if the family’s income or resources are too high for their parents to be eligible for Medicaid. Child Health Plus A covers many children in families where one or both parents work. Child Health Plus A also does not have a resource test. This means that there are no limits on the amount of savings or property a family can own.


• Child Health Plus A Covers More Medical Services than Adult Medicaid: Children enrolled in Child Health Plus A, as well as children and young adults up to age 21 enrolled in regular Medicaid, receive the full package of benefits that adults receive under regular Medicaid. Federal and state law also guarantee children enrolled in Medicaid up to age 21 additional medical services. The federal law is called “Early Periodic Screening, Diagnosis and Testing” or EPSDT.  The state’s version of this law is called the “Child/Teen Health Program.”  These laws give children enrolled in Child Health Plus A and Medicaid regular well-baby and well-child doctor visits, along with a number of tests for various health problems that must be done when each child is the appropriate age. If the tests find a problem, the child must receive all necessary medical treatment.

DETERMINIG ELIGIBILITY FOR CHILD HEALTH PLUS A

If a family’s monthly income is less than the amount shown in this table, the child is financially eligible for Child Health Plus A.  Because Child Health Plus A income guidelines are tied to the age of the child, some children may be eligible for Child Health Plus A, while others may not.  Children not eligible for Child Health Plus A, may be eligible for Child Health Plus B.

Income Eligibility Guidelines for Child Health Plus A*

*As of 01/01/06
**A pregnant woman counts as two people.

Child Health Plus A allows families to deduct certain expenses (such as child care, health insurance costs and limited work expenses) and certain types of income (such as income from a full time student under 21, SSI and Public Assistance) when determining eligibility. The chart is meant only as a rough guide. Families should consult a facilitated enroller or their local Medicaid office for a full eligibility determination.

Finally, children up to age 21 with special health needs that require the comprehensive benefits package of Child Health Plus A may enroll in Medicaid even if their income is above eligibility guidelines. This program is called the Excess Income or "Spend down" program. Children and adults with disabilities can also qualify for Medicaid or the "Spend down" program using special rules for counting their income; see chapter 5A for more information about these programs.

CHILD HEALTH PLUS B

Q. What is Child Health Plus B?

A. Child Health Plus B covers many children under 19 who are not eligible for Child Health Plus A.  Some of these children live in families that earn too much to be eligible for Child Health Plus A, but not enough to be able to afford private insurance.

Child Health Plus B is also available to children who are not eligible for Child Health Plus A because of their immigration status.

Q. What does Child Health Plus B cost?

A. How much a family pays depends on how much the family earns per month.  For some families, Child Health Plus B is free.  Some families have to pay a small monthly amount.  If the family’s income makes them eligible for subsidized coverage they will only need to pay a monthly premium of $9 or $15 for each child (up to 3 children.  For more than 3 children, they would only pay $27 or $45 each month for the family.)   If the family income is higher, they would pay the full premium. There are no co-payments for individual visits or other services. Please see the following table.

Monthly Income Levels for Child Health Plus B

Find a family's monthly income below to see what your cost may be for Child Health Plus B.

*The full premium varies, depending on the Child Health insurance plan you choose, but is about $135.00 per child with no maximum limit.

Q. How does a family apply for Child Health Plus A and B?

A. Families can apply for Child Health Plus A and B at authorized enrollment sites in their neighborhoods, called “facilitated enrollers."

Facilitated enrollments sites include places like community centers, day care centers, schools, and the local Medicaid office. Many Medicaid Managed Care plans are also authorized to enroll children into Child Health Plus A or B.

The facilitated enrollment sites have staff to help families fill out the application form, screen their children for Child Health Plus A or B, and gather the necessary documents.  (Facilitated enrollers can also help adults enroll and submit applications for Medicaid and Family Health Plus).

The application form is easy to fill out.  It is 8 pages long, and called the “Growing Up Healthy” form. It can be accessed electronically here. A copy can also be found at the end of this chapter (print version only).

The “Access NY Health Care” form is an alternative form that can also be used for children applying for Child Health Plus A or B (as well as for adults applying for Family Health Plus or Medicaid- See Chapter 5 and11 for more details). It can be accessed electronically here.

Families will be asked to provide several documents along with their application to verify their eligibility, including proof of age, address, income, citizenship or immigration status (not needed for Child Health Plus B) and identity.  Families are allowed to deduct from their income certain expenses, including childcare and health insurance costs, when screening for which program is appropriate for the client.  Families also must provide proof of these expenses.

A complete documentation checklist can be found here (a print version follows the Growing Up Healthy enrollment form at the end of this chapter).

Families that cannot locate specific documents should not be discouraged from applying.  Facilitated enrollers will help families locate necessary documents to complete their application.

CHOICES YOU NEED TO MAKE WHEN A CHILD ENROLLS IN MANAGED CARE

Children in Child Health Plus A have the same choices about whether to join Medicaid managed care as people who are in regular Medicaid.  Children in CHP A may be required to join a managed care plan unless they are exempt or excluded.

Children in Child Health Plus B must be in a managed care plan; a plan much be chosen when the child enrolls in Child Health Plus B.  All Child Health Plus B managed care plans are required to offer children a standard package of benefits, but plans have different lists of doctors and hospitals that children can use. Families must choose from the plans that serve their particular borough or neighborhood.

Q. What questions should be considered when choosing a Child Health Plus managed care plan?

• What are the child’s health needs? What are the health needs of each child in the family? If one child is already being treated for a medical condition, it may be important to find out which plans will let that child stay with the same doctors and hospitals.
• Does the family already have a doctor for their children that they wish to keep? If the children’s parents want to stay with their present doctor, they need to ask him or her which plans s/he accepts, and then eliminate the remaining plans from the list of possibilities. A smaller number of plans to choose from may make the selection process easier.
• Does the preferred doctor have a waiting list? Physicians in plans often have waiting lists. Applicants need to ask the plans’ Member Services or the physician’s office if their doctor of choice has a waiting list and if new patients can join the list. Families may not be able to get their doctor of choice as their primary care provider (“PCP”). A family also has to find out about waiting lists if they want to continue with their child’s current doctor as his or her primary care physician (PCP).
• Will it be simple for the family to use the managed care plan’s health services? Before joining a plan, the parents need to make sure the location of the plan's doctors, hospitals and clinics is convenient. Also, services are available after work hours and at other times convenient to the families’ needs and that the plan has providers who speak the same language.

Q. What if families want to switch to another primary care provider (PCP) or a whole different managed care plan for their child?

A. To change a child’s primary care provider, call his/her plans’s Member Services Department and request a new primary care provider and give the name of the new physician of choice. Unless the new doctor is unable to take on new patients, families should be able to make the switch.

To switch between managed care plans for Child Health Plus A, the same rules apply to children as those applied to adults enrolled in Medicaid Managed Care(See Chapter 5A).

To switch Child Health Plus B plans, an applicant needs to disenroll his or her child from the original plan and join a new plan.  Families can enroll in the new plan by completing an application with a facilitated enroller at the new health plan or in the community. The facilitated enroller can help disenroll the child from the old plan so that there is no gap in coverage.  Generally, if an applicant completes the new application before the 20th of the month, the child’s new enrollment will be effective the first of the next month; if it is after the twentieth, the new enrollment won’t take effect until the following month. The applicant should notify the child’s old plan’s Member Services Department of the date needed to have the child disenrolled. To avoid a gap in coverage, the family can also ask the old plan for a letter with the effective disenrollment date.  Then, when enrolling the child in a new CHP B plan, the applicant can show the new plan the letter stating the child’s effective date of disenrollment from the previous plan.

WHAT IS NEEDED AFTER A CHILD IS ENROLLED IN CHILD HEALTH PLUS A OR B

Q. What does an individual need from the managed care plan for a child to use health services?

A. Once a child is enrolled in a Child Health Plus B managed care plan, the plan should send three things:

• Child Health Plus B Card: This should arrive in the mail, with an acceptance letter, within 14 days after enrollment.
• Member Handbook. All children who are newly enrolled in a managed care plan should be mailed a Member Handbook. The Handbook or contract explains the rules to follow to get care from the managed care plan.
• Provider Directory. Every managed care plan has a Provider Directory that lists the doctors, hospitals, health centers, dentists and pharmacies that are in its provider network, which are the ones that the enrolled child can use. The family receives the Provider Directory either with the application packet or after their child is enrolled.

HOW TO SOLVE PROBLEMS IN CHILD HEALTH PLUS A OR B

Q. What rights does any child have as a member of a Child Health Plus B program?

A. The child’s family will receive a Member Handbook or subscriber contract from the Child Health Plus A or B managed care plan (CHP B plans must issue a subscriber contract and some may issue a member handbook), which explains the benefits and responsibilities of plan members.

All members in managed care plans in New York State rights which are described in the Managed Care Bill of Rights (Appendix B). The contracts for the Child Health Plus B plans also contain many of the same protections as CHPlus A/Medicaid managed care, such as limits on how long an individual has to wait for care.

Q. What can be done if there are problems with the health care a child gets under Child Health Plus A or B?

A. If a family has a complaint about their child’s health care, the family can file a “grievance,” an “appeal,” or a request for a “utilization review.” The process is described in Chapter 9B, and is the same for members of commercial managed care plans filing grievances and appeals.

Families should first seek to resolve any issues with their health plans.  However, issues that are not resolved promptly by the health plan should be called to the attention of state officials overseeing the Child Health Plus program.  These officials can be reached by calling or writing:

Child Health Plus Program
New York State Department of Health
Division of Planning, Policy and Resource Development
Corning Tower, Empire State Plaza
Albany, NY 12237
(518) 473-0566

SERVICES AVAILABLE FOR TEENAGERS IN CHILD HEALTH PLUS

Q. What services do Child Health Plus A and B offer to teens?

A. Both Child Health Plus A and Child Health Plus B cover many services that are particularly important for teens. The complete Child Health Plus B benefit package is listed on page 2. These include:

• Family planning (birth control and reproductive health) services
• Contraceptive medications and devices
• Medically necessary abortions
• Sexually transmitted disease (STD) testing and treatment
• HIV testing and treatment
• Prenatal, labor, and delivery care

Q. Do teenagers need special doctors?

A. As children become teenagers, their needs change, and they may want to see a doctor who understands and can address these changing needs.  Both Child Health Plus A and Child Health Plus B have doctors and adolescent health centers that specialize in caring for teens (though some may be listed as pediatricians).  Teens can choose different primary care providers from those used by their younger brothers and sisters.

Q. Are doctors allowed—or permitted—to preserve the confidentiality of teenage patients, even from their parents?

A. Generally, teens have the right to expect most services and conversations with their doctor to be kept confidential.  Confidentiality applies to all conversations regarding family planning, substance abuse, and testing and treatment for HIV infection and sexually transmitted diseases (STDs). Teens have a right to receive these services without their parents’ consent. 

But it is important to be aware that individual providers may not follow the law and may have different policies about confidentiality. Also, some doctors and managed care plans send detailed notices and bills for treatment directly to the patient’s home.  Teens should ask about these issues before choosing a doctor, so they will know what to expect.

Q. Can a teenager or minor apply for Child Health Plus A or Child Health Plus B on their own?

A. Sometimes. Teens can apply for Child Health Plus A (formerly Children’s Medicaid) and Child Health Plus B (and minors under age 21 can apply for regular Medicaid) on their own if they fit any one of these categories:

• They are not living with their parents or step-parents
• They are pregnant
• They are married
• They are the parent of a child

However, teens that live with their parents and are not pregnant will need to provide information about their parent’s income, which will be considered when determining eligibility. All teens who do not live with their parents or step-parents and all pregnant teens (whether living with their parents or not) may apply on their own, and their parents income will not be considered when determining eligibility.

Q. How can teenagers receive family planning services with Child Health Plus A?

A. The Child Health Plus A program offers teenagers “free access” to family planning services. This means teens can go to a provider of their choice, in or out of their health plan’s network, and receive services such as contraceptives, abortions, and STD/HIV testing and treatments. Prenatal, labor and delivery care are not included.

Q. How can teenagers receive family planning services with Child Health Plus B?

A. The Child Health Plus B program offers teens many important family planning services, including contraceptive medications and devices and abortions. Child Health Plus B plans should give a list of providers that offer family planning services.  In addition, teenage women—like other women—can receive women’s health services (OB/GYN) without a referral from their primary care provider.  This is known as “direct access.” Unlike Child Health Plus A, however, Child Health B requires the provider to be a part of their health plan’s provider network.

Q. What is the Family Planning Benefit Program (FPBP)?

A. The Family Planning Benefit Program (FBFP) provides family planning services for men and women of childbearing age with net income up to 200% of the federal poverty level. Adolescents up to age 21 who live at home with their parents can apply for the FBFP on their own behalf, and their eligibility will be based on their own income.

Documentation requirements are the same as those for Child Health Plus A and B, and there is no resource test.  To apply, use the “Access NY Healthcare” application (see Chapter 11), or a one-page application available from Medicaid offices and family planning providers.  Like Child Health Plus A and B, renewal enrollment in FPBP is year.

WHAT IMMIGRANTS NEED TO KNOW ABOUT
CHILD HEALTH PLUS A & B

Q. What do immigrants need to know about children’s health coverage?

A. Health insurance is available to all uninsured children in New York State regardless of their immigration status. However, some immigrant families may have some concerns about signing their children up for health insurance and using Child Health Plus A and Child Health Plus B.  

These parents should know that the “Growing Up Healthy” application form—the combined application for both Child Health Plus A and Child Health Plus B—does  not ask for immigration information on any family members except for the children applying for coverage. Similarly, parents who use the “Access NY Health Care” application—the combined application for Medicaid, Family Health Plus, Child Health Plus A and Child Health Plus B—do not have to give immigration information on any family members not applying for coverage.

Q. Will applying for Child Health Plus A or B mean that one’s immigration status is reported to the U.S. Citizenship and Immigration Services/USCIS (formerly Immigration and Nationalization Services/INS)?

A. Some families may be reluctant to apply for health insurance for their children because they are afraid that their immigration status will be reported to the U.S. Citizenship and Immigration Services/USCIS (formerly Immigration and Nationalization Services/INS). Families should know that it is New York State policy NOT to report information on the application to USCIS.

Q. Will using Child Health Plus A or B hurt a child’s chance of getting a green card?

A. Almost never. Some immigrant families may fear that using Child Health Plus A or Child Health Plus B may make them a “public charge.”  People considered by USCIS to be public charges may sometimes have difficulty getting a green card, becoming a citizen, sponsoring a family member to enter the U.S., or traveling in and out of the U.S.

USCIS has decided that using Child Health Plus A or B will NOT affect any family member’s ability to get a green card, become a citizen, sponsor a family member or travel in and out of the U.S. In VERY RARE instances only, USCIS can consider a family member a public charge if that person uses Child Health Plus A to cover long-term institutional care, such as in a nursing home or psychiatric hospital.

ENSURING CONTINUING COVERAGE UNDER CHILD HEALTH PLUS A OR B

Q. Why is it important to recertify for Child Health Plus A or B?

A child is only enrolled in Child Health Plus A or B for one year.  After one year, the child must reapply. This is called “renewal” or “recertification.”  Children enrolled in Child Health Plus A will get notices from Medicaid and children enrolled in Child Health Plus B will get a notice from their health plan.  These notices should come several months before the child’s coverage is scheduled to expire. It is important to act on the renewal application before the year ends to avoid gaps in coverage.

There have been many recent changes in the way families renew coverage for children under Child Health Plus A and B.  In New York City, there are new mail-in renewal forms for both Child Health Plus A and Child Health Plus B that are easier to use.

New Renewal Forms:  New York City started using a consumer-friendly renewal booklet in June 2003, which includes a pre-printed renewal form, renewal information, guidelines and terms, rights and responsibilities for Child Health Plus A, Medicaid and Family Health Plus.  Beginning in September of 2003, health plans offering Child Health Plus B began to use a new Child Health Plus B renewal form. These new forms are simpler and require less documentation than the “Growing Up Healthy” or “Access NY Health Care” applications.

Families May Renew Through the Mail:  Renewal is now a mail-in process for both CHPlus A and B, and no face-to-face meeting with an enroller or a district worker is required. Families who need or want help can call the number(s) listed on the renewal form, or can visit a facilitated enroller or Medicaid office for CHPlus A, Medicaid and Family Health Plus or their health plan for CHPlus B.

If a family’s income has changed, children may be eligible for a different program. In this case, parents may choose to renew the child’s eligibility with the help of facilitated enrollers at community sites or health plans, who will make sure they submit the correct forms to the correct programs.

For example, if a family’s income has gone up, and they mail a Child Health Plus A renewal to the Medicaid office, they will get a notice that their child is ineligible for Child Health Plus A.  They should see a health plan or facilitated enroller to submit a “Growing Up Healthy” application to determine eligibility for Child Health Plus B.

Fewer Documents Required to Renew:  In New York City, Child Health Plus A renewals only require proof of current income and of anything else that has changed since the application, such as immigration status or home address. If a family wants to claim childcare or health insurance expenses, they will also have to provide proof. Families do not have to show proof again for things that don’t change (citizenship, social security number, date of birth).

On the Child Health Plus B renewal form, children will not need to provide any proof of their address to renew their coverage.  The new form also does not require any proof of income, as long as the family provides a social security number for each person whose income is being counted for the child’s insurance. The family can choose not to provide social security numbers for this purpose, and instead provide proof of their current income.  Families can choose to supply proof of income for some family members and provide social security numbers for others.

CHILD HEALTH PLUS B BENEFITS EXPLAINED

New York State Dept. of Health’s Child Health Insurance Program New York City Facilitated Enrollment Lead Agencies

Contact these agencies to enroll someone in CHP/Medicaid:

New York City Child Health Plus Managed Care Plans

* Plan authorized to do facilitated enrollment into Child Health Plus A or B
** Plan authorized to do facilitated enrollment into Child Health Plus B only

• Growing Up Healthy Enrollment Form (PDF)