Medical Assistance: Family Health Plus
What is Family Health Plus?
What services are covered by Family Health Plus?
How can I enroll in Family Health Plus?
What is the Family Health Plus Premium Assistance Program?
Are there co-pays for this program?
What is Family Health Plus?
Family Health Plus provides coverage to adults who do not have health insurance, but have income too high for Medicaid. Parents and childless adults aged 19 through 64 are eligible if they live in New York State, have no health insurance and meet income guidelines.
What services are covered by Family Health Plus?
- physician services
- inpatient and outpatient health care
- prescription drugs and smoking cessation products covered by Medicaid
- X-rays and lab tests
- vision, speech, and hearing services
- rehabilitative services (some limits apply)
- durable medical equipment
- inpatient hospital medical or surgical care
- emergency room and emergency ambulance
- drug, alcohol, and mental health treatment (some limits apply)
- diabetic supplies and equipment
- hospice care
- radiation therapy, chemotherapy and hemodialysis
- dental services (if offered by the health plan)
- Family Health Plus does not pay for long-term care, non-emergency transportation or medical supplies
How can I enroll in Family Health Plus?
Enrollment facilitators and social service district offices answer questions and help you choose a health plan.
Call 1-877-9FHPLUS (1-877-934-7587) or visit the Family Health Plus website.
What is the Family Health Plus Premium Assistance Program?
This program is for individuals and families who are eligible to enroll in or are currently enrolled in their employer sponsored health insurance. In order to be eligible for this program, you must meet income/resource eligibility requirements for the Family Health Plus Program.
The following criteria also must be met:
- must be a resident of New York State and between 19 and 64 years of age;
- must be a citizen of the United States or a Medicaid eligible qualified alien;
- must not be eligible for Medicaid based on income and/or resources;
- and eligible for, or enrolled in, employer based health insurance.
Employer-based insurance must have a standard scope of services and also must be determined qualified and cost effective by the Department of Social Services.
The individual or family will receive comprehensive health care coverage through the health insurance company their employer participates with. If some services are not covered by this insurance and Medicaid allows the service, you will receive it through the Medicaid benefit. The co-pay schedule follows what your employer-based insurance charges, but if they exceed the Medicaid co-pay schedule, they can be billed to Medicaid or you can be reimbursed by the Department of Social Services.
The Premium Assistance Program also pays for your share of the premium for your employer based insurance and reimburses for deductibles, co-insurance, and co-payments that exceed the Family Health Plus co-payment schedule. If you have a waiting period before you can enroll in the employer-based health plan, you can be temporarily placed on Family Health Plus for the adults in your household and any children under 19 will be evaluated for Medicaid during this time.
You can apply at the Department of Social Services, N. Court St. Wampsville, NY 13163 by calling (315)366-2211 Monday-Friday 9 a.m.- 5 p.m. You can also utilize a facilitated enroller by calling 1-877-934-7587 to find an enroller in your area of the county.
Are there co-pays for this program?
Family Health Plus has co-pays for certain services they provide. If you are unable to pay these, your provider can bill you, but you are still responsible for them. Children under 21 and pregnant women (until 60 days postpartum) are exempt from paying co-pays.
The co-pay schedule is as follows:
- Physician Visits: $5.00
- Brand Name Prescriptions: $6.00
- Generic Prescriptions: $3.00
- Radiology Services: $1.00
- Lab Tests: $ .50
- Non-urgent ER Visits: $3.00
- Inpatient Hospital Stay: $25.00
- Covered over-the-counter drugs; lancets; test strips; enteral formula: $1.00
- Smoking Cessation Products: $ .50
- Dental Visits: $5.00 (Up to a total of $25.00/year)