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Medicaid Managed Care

Views: 25397
Posted: 14 Sep, 2011
by Sarina Master (Legal Aid Society)
Updated: 15 Apr, 2014
by Valerie Bogart (New York Legal Assistance Group)

I – WHAT IS MEDICAID MANAGED CARE?

Most, but not all Medicaid beneficiaries in New York State who do not have Medicare must now join a "mainstream" Medicaid managed care plan. 

Law and Regulations:  N.Y. Soc. Servs. L. §364-j (Amended L. 2011 Ch. 59).   Regulations at 18 NYCRR 360-10.  

In regular or fee-for-service Medicaid,  beneficiaries can go to any doctor who takes Medicaid. This is called fee-for-service because the doctor or provider gets a fee every time he/she provides a service to a Medicaid beneficiary. In managed care, the plan is paid a capitated rate (flat monthly fee) to provide for nearly all of the beneficiary’s health care needs.

In Medicaid managed care, enrollees can only see the doctors and other health providers in their plan’s network, and must follow the plans rules for accessing care. In addition, they will be assigned a primary care provider and must go to this provider in order to get a referral for specialty care and prior authorizations for non-emergency hospitalizations and many other services.

Many (but not all) adult Medicaid recipients who DO have Medicare must join a different type of managed care plan - a Managed Long Term care plan.  See more here. 

 Medicaid Redesign Team - New Rules and New Populations

Since the 2011 state budget laws adopted the recommendation of the Medicaid Redesign Team, the rules about which benefits will continue to be offered on a fee-for-service basis have changed drastically. The result is that 3.3 million Medicaid recipients will be affected by the changes to the Medicaid Managed Care benefit package. Also, the rules about who will continue to be exempt or excluded from mandatory Medicaid managed care enrollment have changed. To read an article  that explains the MRT process, the specific changes and the timeline for their implementation, click here or see the attachment. Because the implementation is still ongoing, throughout this article you will find a notation "new as of (date)" and a link to an article with more information where available. 

See Information on State MRT website on new populations and services under Managed Care- 

Beneficiaries must keep their regular Medicaid card. They will need it to get important benefits that are not covered by their Medicaid managed care plan. These are called “carved out” services because they are “carved out” of the Medicaid managed care benefit package and still paid for by fee-for-service Medicaid.  See 364-j(3)(d)(Amended by 2011 Sess. Law News of N.Y. Ch. 59); see also Appendix K of the Medicaid Managed Care Model Contract (as amended August 2011) for a list of which services are covered by the managed care plans and those that remain covered by regular Medicaid. Currently, carved out services include:

  1. Mental Health Services for SSI recipients and SSI-related beneficiaries

  2. COBRA Case Management

  3. HIV Adult Day Health Care

  4. Medicaid Service Coordination and other Long Term Care Services for the Developmentally Disabled

  5. Non-Emergency Medical Transportation Services (beginning 10/1/11)

II. MANDATORY ENROLLMENT/ASSIGNMENT

Medicaid recipients in all  counties plus New York City are generally required to join a managed care plan)    

  • In New York City, and  most upstate counties (go to Slide15) recipients receive mandatory enrollment packets from New York Medicaid Choice, a/k/a Maximus, a private company contracted to process managed care enrollments and disenrollments.  (Contact:  1-800-505-5678 TTY/TDD (800) 329-1541
  • Currently individuals will receive mandatory enrollment packets from New York Medicaid Choice or their Local Department of Social Services and will be randomly assigned into a Medicaid managed care plan if they do not choose a health plan.
 
·        New as of October 1, 2011, all newly mandated Medicaid recipients will have 30 days to choose a plan, regardless of disability status. New Medicaid applicants will be required to choose a health plan at application. N.Y. Soc. Servs. L. §364-j(4)(f)(i)

NINE MONTH “Lock-In”:   Once enrolled in a plan, enrollees should get a member handbookexplaining how managed care works. Recipients have 90 days from their initial enrollment date to change plans. If they do not switch within 90 days, they are locked-in to the plan whether they chose the plan or were automatically assigned, and cannot get out for the following 9 months, unless they have “good cause” to do so. After the lock-in period ends, recipients can change plans for any reason at any time. However, the lock in applies 90 days after each new enrollment. Enrollees are supposed to receive notice of this right 60 days prior to the end of the lock-in period.

III.   WHO DOES NOT HAVE TO JOIN A MANAGED CARE PLAN? Exemptions and Exclusions

Two groups of people do not have to join: people who are exempt and people who are excluded. See N.Y. Soc. Servs. L. §364-j(3);

Exempt: People who can decide if they want to join are exempt from Medicaid managed care. See N.Y. Soc. Servs. L. §364-j(3)(b), (e).

Excluded: People who cannot join a Medicaid managed care plan are excluded. See N.Y. Soc. Servs. L. §364-j(3)(c).

CHART: EXEMPTIONS AND EXCLUSIONS REMAINING AFTER MRT IMPLEMENTATION (4/2012)
WARNING:  The 2013 state budget authorizes the State Dept of Health to remove these exemptions and exclusions.. so stay tuned later in 2013.  See this article and 

MRT 1458: Care Management Population and Benefit Expansion, Access to Services, and Consumer Rights

Exemptions
Exclusions
  • Recipients with a chronic medical condition who are in active treatment with a specialist who does not accept any MMC plan (duration of exemption is 6 months - more limited as of 10/1/11)

  • Recipients enrolled in Medicare Advantage

  • Native Americans

  • OPWDD Waiver, Traumatic Brain Injury waiver, Care at Home Waiver for children, or Nursing Home Transition & Diversion Waiver recipients and those with similar medical needs and characteristics -- called "waiver look-alikes."   But as of April 1, 2013, Lombardi program participants without Medicare must enroll in managed care plans.  See here

  • Recipients with original Medicare

  • Recipients with other comprehensive insurance

  • Recipients enrolled in the Medicaid Spend-down or Excess Income program;

  • Recipients with limited Medicaid eligibility (for example, Medicaid for the treatment of an emergency condition,  tuberculosis (T.B.) related services, Breast and Cervical Cancer);

  • Recipients receiving hospice services

  • FOSTER CARE -- Children in agency-based foster care will be excluded until October 2014. Children in non-agency based foster care and the Bridges to Health Medicaid Waiver OUTSIDE NYCare subject to mandatory enrollment in managed care as of April 1, 2013, under slightly different enrollment procedures than other (see this section)

 A chart with exemptions and exclusions phased out over MRT's three year implementation schedule appears in this detailed article, with a chart that can be found here  Also see NYC HRA Chart of Exemptions and Exclusions, updated March 27, 2012.  

 Here is a sample letter being sent in summer and fall 2012 telling people they are no longer exempt from mandatory enrollment, telling them to expect to receive a letter requiring them to choose a plan.   If they are a waiver "look-alike" they should follow instructions in this Alert. 

New Populations Required to Enroll in Managed Care (2013, 2014)

A.   NURSING HOME RESIDENTS - MANDATORY ENROLLMENT-  

Adults age 21+ becoming permanent nursing home residents after March 1, 2014 will be required to enroll in managed care plans starting in June 2014 in downstate areas (NYC, Long Island, and Westchester) (delayed from March 2014) . Upstate mandatory enrollment will begin in December 2014 (delayed from September 2014).  See State DOH Policy 

Transition of Nursing Home Population and Benefit into Medicaid Managed Care - March 20, 2014 Presentation   reviewed timelines, network requirements, reimbursement policies and other key areas of concern  (NOTE dates not updated yet to reflect tentative start date of June 1, 2014)

The type of managed care plan in which the individual must enroll depends on whether or not they receive Medicare.  

  • Those with Medicare (dual eligibles) will have to enroll in a Managed Long Term Care (MLTC) plan, unless otherwise exempt.

  • Those without Medicare will have to enroll in a "mainstream" Medicaid managed care plan. 

Anyone already in a nursing home before June 1, 2014 will not have to enroll in a managed care plan, and will continue to have Medicaid pay for their nursing home care on a "fee for service" basis. 

Those who are already enrolled in an MLTC or mainstream Medicaid managed care plan in the community, who come to need long-term nursing home placement after June 1, 2014 (if in the downstate mandatory area) or in other areas when they become mandatory, will no longer be disenrolled from the plan when they need nursing home care.  They will need to choose a nursing home within the plan's network (or may sometimes change plans) and the plan will still manage their care in the nursing home. 

 See other MRT expansion documents at MRT 1458: Care Management Population and Benefit Expansion, Access to Services, and Consumer Rights

B.  FOSTER CHILDREN - NEW MANDATORY ENROLLMENT in effect April 1, 2013 OUTSIDE OF NYC

 C.  LOMBARDI PROGRAM RECIPIENTS who do not have Medicare - as of April 1, 2013 must enroll in Medicaid managed care plans 

 IV. Enrolling in and Disenrolling from Medicaid Managed Care

Voluntary Enrollment

Beneficiaries can enroll in a Medicaid managed care plan voluntarily at any time. They can join by calling a community based facilitated enroller, a Medicaid managed care plan directly or by calling New York Medicaid Choice at 1-800-505-5678 - TTY/TDD (800) 329-1541.   NY Medicaid Choice is a private company which has been contracted by 24 local districts and New York City to help enroll people in managed care. NY Medicaid Choice has response standards it is required to meet. They are required to answer the phone quickly and have operators who speak many languages.   In counties that have not contracted with NY Medicaid Choice, recipients are enrolled into managed care plans by the Local Department of Social Services.

Mandatory Enrollment:

New as of October 1, 2011, all newly mandated Medicaid recipients will have 30 days to choose a plan, regardless of disability status. New Medicaid applicants will be required to choose a health plan at application or they will be automatically assigned to a random plan by the State Department of Health. N.Y. Soc. Servs. L. §364-j(4)(f)(i) (Amended by 2011 Sess. Law News of N.Y. Ch. 59). Newly mandated Medicaid beneficiaries who are required to choose a health plan beginning in October 2011, who reside in counties with a contract with NY Medicaid Choice will be sent mandatory enrollment packets on October 1, 2011. Medicaid recipients who reside in counties who do not contract with NY Medicaid Choice will receive mandatory enrollment packets upon recertification or when a change is made to their Medicaid case such as a change in address or household size.

Disenrolling, Transferring and Exemptions

People who would like to disenroll or transfer out of their Medicaid managed care plan, or who think they may still be exempt or excluded from Medicaid managed care, should call NY Medicaid Choice at: 1-800-505-5678 or their local department of social services. See article on Advocacy & Exemptions.  See 18 NYCRR 360-10.6 Good cause for changing or disenrolling from a Medicaid managed care organization (MMCO) 

V.  Lists of Plans - Contact Information

NYC HRA List of  NYC plans-- Mainstream Managed Care Plans, HIV SNPs, Managed Long Term Care plans, and Medicaid Advantage Plans  (updated January 2014)

Statewide Plan Contact information - (listed by county or by plan)

New 10/2012 --Pharmacy Benefit Information Website -- http://pbic.nysdoh.suny.edu --  Phase I (Oct. 2012) provides access for members and providers looking for information on the drugs and supplies covered by different Medicaid and Family Health Plus managed care health plans. In the near future, the Department plans to release phase two of the project, which will allow interactive comparison of coverage searches.

VI. Accessing Services - what is in the plan's service package? 

 Medicaid managed care plans work very much like private insurance managed care plans. As we describe above, enrollees can only see the doctors and other health providers in their plan’s network, and must follow the plans rules for accessing care. In addition, they will be assigned a primary care provider and must go to this provider in order to get a referral for specialty care and prior authorizations for non-emergency hospitalizations and many other services. Because Medicaid must provide all medically necessary care, there are benefits which traditionally are not part of a private insurance such as transportation, medications, skilled nursing care, personal care services and PERS. Pursuant to the MRT changes, enrollees in a Medicaid managed care plan will begin to receive all of there services from their plan on an extended timeline. A summary appears in the chart below. 
Date Benefit Offered Service
8/1/11
Personal Care Services --  click here for article 
10/1/11 Pharmacy Benefits - Until January 1, 2012 plans must provide a one time 30 day supply of non-formulary drugs and/or a 30 temporary day fill of previously authorized formulary drugs without requiring new authorization regardless of plan utilization management controls. 

For more information on Medicaid Managed Care’s Prescription Drug Carve-In click here  or see the attached article below

Pharmacy Benefit Information Website -- http://pbic.nysdoh.suny.edu --  Phase I (Oct. 2012) provides access for members and providers looking for information on the drugs and supplies covered by different Medicaid and Family Health Plus managed care health plans. In the near future, the Department plans to release phase two of the project, which will allow interactive comparison of coverage searches.

Effective Jan. 1, 2013, managed care plans must cover ATYPICAL ANTIPSYCHOTIC drugs, INCLUDING NON-FORMULARY DRUGS, if prescribing MD says they are medically necessary. (provider prevails").  part of 2012 State Budget 

 10/1/2011

Transportation Services - but as of Jan. 1, 2013, transportation is again "carved out" of managed care in NEW YORK CITY only and handled centrally Logisticare.  See HRA Alert

1/1/2012 Personal Emergency Response Systems (PERS)
7/1/2012

Dental - see guidelines and Q&A- not all plans provide dental, Academic Dental Services access allowed, etc.

10/2012

Orthodontia - see guidelines and Q&A

11/1/2012

Consumer Directed Personal Assistance services (CDPAP) Services - See DOH Policy on CDPAP Transition,  Responsibilities of the Health Plan , Fiscal Intermediary Agreement

8/1/2013

Adult Day Health Care (ADHC), AIDS Adult Day Health Care, TB Directly Observed Therapy (DOT),

10/1/2013

HOSPICEAs of October 1, 2013, the provision of hospice services to enrollees in mainstream Medicaid managed care (MMC) is the responsibility of the MMC plan, instead of fee-for-service (FFS) Medicaid.   MMC members who first come to need hospice while enrolled in their MMC plan must access it through their MMC plan.  But if they were already receiving hospice services outside of their MMC plan as of Oct. 1, 2013, they are "grandfathered in" and may continue receiving those hospice services outside of their plan.  See DOH Guidelines for the Provisions of Hospice Services in Mainstream Medicaid Managed Care  (10/1/2013)

Hospice Transition to Managed Care Webinar (PDF, 186KB)

Hospice Transition to Managed Care Benefit Package Questions and Answers 

 

 VII.  Resources Online - 

Check for updates here  http://www.health.ny.gov/health_care/managed_care/  for the following links:

Medicaid Section 1115 Demonstration Projects

Managed Care Quality Reports -- http://www.health.ny.gov/health_care/managed_care/reports/  (external reviews, satisfaction surveys, utilization data, etc.)

Medicaid Managed Care Enrollment Statistics - monthly number enrolled in every plan in NYS  Monthly Medicaid Managed Care Enrollment Report

New 10/2012 --Pharmacy Benefit Information Website -- http://pbic.nysdoh.suny.edu --  Phase I (Oct. 2012) provides access for members and providers looking for information on the drugs and supplies covered by different Medicaid and Family Health Plus managed care health plans. In the near future, the Department plans to release phase two of the project, which will allow interactive comparison of coverage searches.

Legal Aid Society
Health Law Unit
NYC Helpline: 212-577-3575
Upstate Helpline: 888-500-2455
Last Updated September 30, 2011,   April 2013 andApril 2014

Attached files
file MICSA Transportation NYC.pdf (324 kb)
file MAPDR-21 Medicaid Managed Care Exemptions and Exclusions.pdf (55 kb)
file MRT Changes to Medicaid.pdf (190 kb)
file Microsoft Word - MMNY- MMC Fact Sheet- Pharmacy for Consumers Final 9_29_11.pdf (99 kb)
file MMNY - MMC Fact Sheet Advocate - Personal Care.pdf (214 kb)
file MAPDR-05 Provider ID and Plan Code MMC MAP MLTC 2014-09-25.pdf (133 kb)
file DOH Non-dual New Populations and Benefit PPt.ppt (969 kb)
file Alert 2012-9-19 Managed Care Waiver Lookalikes Exemption.pdf (51 kb)
file redacted managed care enrollment etter 8-7-12.pdf (438 kb)

Also read
document Behavioral Health Carve Outs
document SDOH Transitional Care Policy
document Managed Long Term Care
document Medicaid Home-and-Community-Based Waiver Programs in New York State
document Medicaid Transportation in NYS
document New York Dramatically Expands Mandatory Managed Care for Medicaid Beneficiaries
document Applying for Medicaid Personal Care Services in New York City - BIG CHANGES SEPTEMBER 2012
document New York Medicaid Expansion under the ACA ... and other 2013 budget changes
document Consumer Advocacy on the FIDA Demonstration - Fully Integrated Dual Advantage - Managed Care Covering Medicare and Medicaid Services Starting 2015

External links
http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/
http://www.health.ny.gov/health_care/managed_care/reports/
http://pbic.nysdoh.suny.edu
http://www.communityhealthadvocates.org/node/690

Also listed in
folder Medicaid -> Getting Started
folder Medicaid -> Medicaid Managed Care

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