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)
CMS Special Terms & Conditions (ST&C) of the 1115 Waiver - this is the agreement between CMS and NYS Dept. of Health that has all of the terms of the 1115 waiver governing managed care. Posted here - direct links NY STCs Effective (Web) - (PDF) - 8.10.20
Model Managed Care Contract Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan Model Contract (2019) (check for updates here)
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 join a "mainstream" Medicaid managed care plan.
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 2019). Currently, carved out services include:
II. MANDATORY ENROLLMENT/ASSIGNMENT:
Medicaid recipients in all counties plus New York City are generally required to join a managed care 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. See grounds for good cause to change plans in Model Contract Appendix H (begins p. 364 of the PDF)
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).
SEE NYS DOH List of Exemptions & Exclusions from Mainstream Managed Care, updated 11/29/23
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 - 2021)
A. NURSING HOME RESIDENTS - MANDATORY ENROLLMENT-
Adults age 21+ becoming permanent nursing home residents are required to enroll in managed care plans starting in Feb. 2015, See this article.
C. LOMBARDI PROGRAM RECIPIENTS who do not have Medicare - as of April 1, 2013 must enroll in Medicaid managed care plans
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.
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, HARP, PACE, FIDA-IDD, MAP, and Managed Long Term Care plans (updated 12/30/2021)
Statewide Plan Contact information - (listed by county or by plan)
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.
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.
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Last Updated September 30, 2011, April 2013 andApril 2014