New York Dramatically Expands Mandatory Managed Care for Medicaid Beneficiaries

Many people who used to be exempt from mandatory enrollment in Medicaid managed care have been receiving notices in summer and fall 2012 telling them that their exemption has ended, and that they now have 30 days to enroll in a managed care plan.   This type of managed care is sometimes called "mainstream" managed care and is for Medicaid recipients who do not have Medicare.   It is different from mandatory managed long term care, which is being implemented in NYC in October 2012 for dual eligibles -- those who have Medicaid AND Medicare -- who need Medicaid home care.    Here is a sample notice explaining that the exemption from enrollment from managed care is over, telling the individual to expect another letter giving them 30 days to select a plan. 

One of the exemptions that is being eliminated is for "waiver look-alikes," people who have the same characteristics and needs as
consumers enrolled in Medicaid waiver programs such as Traumatic Brain Injury, Care at Home, Home and Community Based Services for the Developmentally Disabled, and the Nursing Home Transition Waiver, but are not enrolled in a waiver program.    See info on these waivers.   On Sept. 19, 2012, NYC HRA Medicaid Program (MICSA) issued an important Alert stating that --

Such consumers may decide they now want to apply for a waiver program or
designation as developmentally disabled. Because this process may take more than
30 days, SDOH has decided to allow an exemption for up to six months for non -
dually eligible consumers who are in the process of applying for a waiver program or
designation as developmentally disabled. To qualify for this exemption, consumers
must call NY Medicaid Choice at 800-505-5678, to inform staff that they are applying
for waiver services.

Many people who are in this category were receiving personal care services from the CASA, and in the transition to mainstream Managed care are losing those services.  If they apply for one of these waivers,  they can then request the exemption above from enrolling into mainstream Managed care.

The changes now being implemented are explained in this article published in the Summer, 2011 edition of the Legal Services Journal and provides an overview of the 2011 legislative changes in New York's Medicaid program that have the effect of expanding the state's use of managed care. 

The article covers expansion achieved through elimination of population exemption and exclusions, as well elimination of service "carve-outs," such as pharmacy and personal care services.  The article includes a timeline for implementation of each of the various provisions.

New York Dramatically Expands Mandatory Managed Care for Medicaid Beneficiaries