Medicaid Managed Care

Law and Regulations    

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

FEDERAL – 42. C.F.R Part 438 (amended extensively in 2016, with changes going into effect in NYS on rolling basis, including new appeal rules starting May 1, 2018 requiring “exhaustion” of internal plan appeals before requesting a fair hearing to appeal a plan’s determination to deny, reduce or stop services.)  Other 2016 changes in federal regulations are summarized by the National Health Law Program here (scroll down to Medicaid Managed Care Final Regulation Series)    

I – WHAT IS MEDICAID MANAGED CARE?

Most, but not all Medicaid beneficiaries in New York State who do not have Medicare and who do not have a “spend-down” or other primary health insurance, must now join a “mainstream” Medicaid managed care plan. 

• 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 bills Medicaid directly 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 may 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.  The network providers bill the plan directly, not NYS Medicaid.

Most adult Medicaid recipients who DO have Medicare and need long term care in the community (home care) 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 Required to Enroll in Managed Care Plans

In 2011, the state enacted recommendations of the Medicaid Redesign Team to expand the categories of people required to enroll in Medicaid managed care, and the types of services covered by these plans, have expanded greatly. The result is that 4.5 million Medicaid recipients are affected by the changes to the Medicaid Managed Care benefit package. Also, very few people without Medicare  continue to be exempt or excluded from mandatory Medicaid managed care enrollment.

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. Fewer benefits are being carved out and still provided through fee-for-service Medicaid.  See 364-j(3)(d)(see also Appendix K of the Medicaid Managed Care Model Contract (as amended August 2011).   Currently, carved out services include:

1. Mental Health Services for SSI recipients and SSI-related beneficiaries – – but see this article on the roll-out of covering behavioral health by  managed care plans directly or through HARPs” starting 2016.

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

3. Non-Emergency Medical Transportation Services (carved out beginning 10/1/11) – see this article

4. Other services have recently been carved into the Medicaid managed care benefit package.  See this section.

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 Medicaid applicants are 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 handbook explaining 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 (current as of 6/2015 with planned changes in 2016-17)

A chart with exemptions and exclusions phased out over MRT’s t implementation schedule appears in this detailed article, with a chart that can be found here  

 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 and Services “Carved Into” benefit Package (2013 – 2016)

A.   NURSING HOME RESIDENTS – MANDATORY ENROLLMENT–  

Adults age 21+ becoming permanent nursing home residents after Feb.  1, 2015 will be required to enroll in managed care plans starting in Feb. 2015, with dates varying around state.  See this article.  

B.  FOSTER CHILDREN – NEW MANDATORY ENROLLMENT in effect April 1, 2013 OUTSIDE OF NYC  and all NYC and other agency-based foster children by Jan. 2017

 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. What Services are 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. 

During the time before transition, a stakeholder work group continues to meet (including payers, consumer representatives, providers of services and the chairs of the assembly and senate health committees) to ensure a thorough and thoughtful discussion on how to best transition these very sensitive populations to managed care in a way that will ensure that these populations do not end up in more costly institutional settings.

 VII.  Resources Online – 

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

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