IN THIS ARTICLE
* Complaints - Where to File
*Law & Regulations & Model Contracts, CMS Special Terms & Conditions
2 - Mandatory Enrollment for Most People with Medicaid - and LOCK-IN
3 - Who is Exempt or Excluded from Enroling in Managed Care
4 - Enrolling and Disenrolling in Managed Care
7. Managed Care Appeals and Hearings
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 on the NYS 1115 Waiver Information Webpage (click on MRT Plan Current STCs -
Model Managed Care Contract March 1, 2024, Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Plan Model Contract (PDF (check for updates here)
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 or "health 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.
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. Very few people without Medicare continue to be exempt or excluded from mandatory Medicaid managed care enrollment. See more here about who is required to enroll and who is exempt or excluded.
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:
Prescription Drugs (carved out in April 2023).
Medicaid Service Coordination and other Long Term Care Services for the Developmentally Disabled
Non-Emergency Medical Transportation Services (carved out beginning 10/1/11) - see this article
Other services have recently been carved into the Medicaid managed care benefit package. See this section.
Medicaid recipients statewide are generally required to join a managed care plan, unless they are exempt or excluded (see here)
· 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
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 ONLY 6 months - SINCE 10/1/11)
Native Americans
OPWDD Waiver (BUT new DD waiver in planning)
Traumatic Brain Injury waiver (carve-in delayed until 1/2022, just extended in 4/1/2018 NYS budget)
Care at Home Waiver for children (but will be carved in Jan. 2017)
Nursing Home Transition & Diversion Waiver recipients carve-in delayed
EXCLUSIONS:
Recipients with original Medicare
Recipients with other comprehensive Third Party Health Insurance (scheduled to be carved in Dec. 2017 but delayed)
Recipients enrolled in the Medicaid Spend-down or Excess Income program (but scheduled to be carved in Dec. 2017 but delayed);
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 at time of enrollment
NO LONGER EXEMPT - FOSTER CARE Children - July 2021 REQUIRED TO ENROLL IN MANAGED CARE (see this section)
MRT 1458: Care Management Population and Benefit Expansion, Access to Services, and Consumer Rights
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.
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.
Since 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)
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 - NYS DOH
NY Medicaid Choice Brochures & lists - scroll down to HEALTH PLAN LISTS - Individual & Family Health plans - by region of state. and Health & Recovery Plans (HARP) plan lists.. Scroll down further to lists of Long Term Care plans by region.
6. What Services are in the plan's service package?
| Date Benefit Offered | Service newly covered by Managed Care plans since 2011 (previously "carved out" and provided outside of plan |
| 8/1/11 |
Personal Care Services -- Plans must cover this service in using the same standards that apply in fee for service - see this article. See this article for how to request this service. Starting May 16, 2022, requests on a standard time line will be refered to the NY Independent Assessor (NYIA) for assessment, and then the plan will make the decision on the amount of hours. See info here about NYIA
|
| 10/1/11 | Pharmacy Benefits -
For more information on Medicaid Managed Care’s Prescription Drug see this article -- this benefit will be carved out of the Managed care benefit package in April 2023. |
| 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. . See this article for how to request this service. Starting May 16, 2022, requests on a standard time line will be refered to the NY Independent Assessor (NYIA) for assessment, and then the plan will make the decision on the amount of hours. See info here about NYIA |
| 8/1/2013 |
Adult Day Health Care (ADHC), AIDS Adult Day Health Care, TB Directly Observed Therapy (DOT),
|
| 10/1/2013 |
HOSPICE - As 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 |
| Jan. 2015 | Comprehensive Medicaid Case Management, HIV COBRA |
| Feb. 2015 | Nursing Home benefit added for Managed Care in NYC (no longer disenrolled from plan after 60-days in NH). See more here. |
| Apr.. 2015 | Nursing Home benefit added for managed care in Long Island & Westchester. See more here |
| July 2015 | Nursing Home benefit added for managed care in Rest of State See more here |
| Oct. 2015 |
Behavioral Health Services - these were CARVED OUT of Managed Care benefit package and will be carved-in in two timelines upstate and NYC, with adult and children phased in separately. See more here and on the State MRT website Also for non-dual eligibles in NYC:
HCBS Waiver - OMH (Non Duals) |
| DELAYED |
Nursing Home Transition & Diversion Waiver - NOTE that 2016-17 State Budget enacted 3/31/16 delays the transition of TBI and NHTD waiver populations to managed care until Jan. 1, 2018 – for info contact Traci Allen The TBI and NHTD populations are relatively small (TBI contains about 2,800 persons; NHTD contains about 2,000); consequently, the program’s budgets are relatively small, but the population’s needs are great and their stability fragile. These individuals qualify for nursing home placement, but under these Medicaid waivers they receive specialized services that keep them safe and functioning in the community and avoid institutional placement. there is concern that the transition plan is not being developed with adequate stakeholder involvement. 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. Hemophilia blood factors |
| DELAYED | Traumatic Brain Injury Waiver- 2016 State Budget delays the transition of TBI and NHTD waiver populations to managed care until Jan. 1, 2018. See note above in Jan. 2016 re Nursing Home Transition waiver. See more info about TBI waiver here. |
| DELAYED | Assisted Living Program residents (non-duals AND Dual eligibles) (NOT IMPLEMENETED - postponed) |
| Jan. 2017 |
Bridges to Health (B2H) - All Categories (Non Duals) - see info here |
| EXCLUDED | Spend-Down population (had been excluded from Managed Care) |
| July 2021 | Foster care population |
In 2016, the federal Medicaid agency finalized changes in procedures for appealing adverse decisions on Medicaid managed care plans. See this article explaining the procedures - which apply both the regular Medicaid managed care health plans and to Managed Long Term Care plans, even though the title of the article says it is about MLTC. Also see this article.
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.