Health Care Access and Improvement

Medicaid Managed Care in New York City

In July 1997, the Federal Government, through the Centers for Medicare and Medicaid Services (CMS), approved an 1115 Waiver for New York State. The 1115 Waiver allows New York State to mandate most Medicaid recipients to enroll in managed care plans in order to continue to receive Medicaid benefits. The program, called New York Medicaid CHOICE in New York City was approved by CMS on July 30, 1999. It was implemented throughout New York City boroughs in five phases based on zip code. The last phase was implemented in September 2002. Enrollment into a Medicaid managed care plan is now mandatory for most Medicaid recipients.

Effective November 2005, Medicaid eligibles in receipt of SSI or who were SS-related (disabled, blind, 65years of age and older), and not receiving Medicare, became subject to mandatory enrollment.

In September 2010, the State Department of Health will begin to expand mandatory managed care enrollment in New York City to Medicaid beneficiaries with HIV/AIDS. Persons with HIV/AIDS who are currently exempt based on their HIV infection will no longer be considered exempt from mandatory enrollment in Medicaid Managed Care. HIV+ patients with Medicare, ADAP, or other exemptions or exclusions, or private insurance will not be affected by this change.

Medicaid eligible persons are notified of the requirement to enroll into a Medicaid managed care plan by mail following initial eligibility for Medicaid. New York Medicaid CHOICE will mail an enrollment package to the Medicaid consumer. The enrollment package for the general population includes the following:

• • The New York Medicaid CHOICE Guide
• • A health plan list which includes participating hospital affiliations
• • A Consumer's Guide to Medicaid Managed Care in New York City
• • Mandatory notice letter
• • An enrollment form & a stamped return envelope

The consumer must return the enrollment form to New York Medicaid CHOICE! The consumer has 60 days to choose a health plan.

If the consumer does not return the enrollment form or contact New York Medicaid CHOICE:

1. A 30-day reminder notice is mailed out.
2. 15 days before 60 days are up - the consumer receives a 2nd reminder notice and is notified of pending AUTO-ASSIGNMENT into a health plan, the name of the health plan and the effective date of enrollment.
3. On the 60th day, the consumer is enrolled into that health plan. A confirmation packet which includes the name of the health plan and a Risk Assessment Form is sent to the consumer.

Telephone Enrollments: To avoid auto-assignment, consumers can enroll by telephone at any time by calling the New York Medicaid CHOICE 1-800-505-5678. Enrollment is confirmed by mail. The Health Risk Assessment will be conducted by telephone.

The enrollment package for the SSI consumer includes the following:

• The New York Medicaid Choice Guide
• The health plan list which includes hospital affiliations
• Mandatory notice
• A Consumer Guide to Medicaid Managed Care in NYC
• An enrollment form and a stamped return envelope

SSI consumers have 90 days to choose a health plan.

If the SSI consumer does not return the enrollment form or contact New York Medicaid CHOICE:

• A reminder notice is mailed on the 30th day, which includes the notice and a health plan list
• An Intent to Default Notice is mailed on the 45th day, which also includes the notice and a health plan list
• Auto-assignment confirmation notice is mailed on the 90th day, confirming enrollment into a Medicaid managed care plan for consumers who have failed to respond to previous notices. Notice includes health risk assessment form and business reply envelope. The health risk assessment is a valuable tool that is forwarded to the health plan. It captures basic health information on the consumer, which assists the health plan in determining the need for disease management or case management services, or other special programs, such as smoking cessation classes. Health plans are also required to send their own health risk assessment forms to new enrollees.

Telephone enrollments: To avoid auto-assignment, SSI consumers can enroll by telephone at any time by calling the dedicated SSI consumer assistance help line: 1-800-774-4241.Enrollment is confirmed by mail.

The Health Risk Assessment is a valuable tool that is forwarded to the health plan. It captures basic health information on the consumer, which assists the health plan in determining the need for disease management or case management services, or other special programs such as smoking cessation classes or pre-natal care. Health plans are also required to send their own risk assessment forms to new enrollees.

Who is Eligible to Enroll?

All persons in the following Medicaid -eligible beneficiary categories who reside in the service area are potentially eligible for enrollment:

• Single Adults/Childless Couples - Cash assistance and Medicaid only
• Low income families with children - Cash assistance and Medicaid only
• Aid to families with Dependent children - Medicaid only
• Pregnant women whose net available income is at or below 200% of the federal poverty level
• Children including those eligible at or below the expanded Medicaid income levels of 100% (6-18) years of age; 133% (1-5) years of age, and 200% (up to 1 year of age) of the federal poverty level
• Transitional Medical Assistance Beneficiaries
• Person in receipt of Supplemental Security Income (cash benefit)
• Certified blind or disabled persons (Medicaid only)

Persons in the same family can enroll into different Medicaid Managed Are Plans, effective October 2005.

Does Everyone Have to Enroll into a Medicaid Managed Care Plan?

Not all Medicaid recipients will have to enroll. Some persons are exempt from mandatory enrollment. Exempt consumers can enroll in a plan or remain on fee-for-service Medicaid. Some Medicaid recipients are required to stay in traditional Medicaid. Some Medicaid recipients are required to stay in traditional Medicaid. These persons are excluded from Medicaid managed care.

How Does Medicaid Managed Care Work?

Persons in receipt of Medicaid benefits can enroll currently into one of the health plans contracted with New York City (PDF)Other languages: [En Español]. Consumers who are HIV+ can enroll into one of the 10 health plans contracted with New York City or into one of three Special Needs Plans (SNPs) that also contract out with New York City.

For consumers who are HIV+ and reside in Staten Island will have two choices for joining a managed care plan.

• Staten Island residents can choose to enroll in any HIV SNP. SNPs are able to establish limited networks with health care providers in Staten Island. Since we expect that a SNP will not have a full range of network providers on Staten Island, members must use the SNP network in other boroughs for services. SNPs and New York Medicaid CHOICE will inform prospective members about the SNP network of participating providers and the networks of participating providers and the network’s limitations.
• People with HIV may also choose to enroll in one of the nine mainstream managed care plans serving Staten Island. The mainstream plans may have both Staten Island providers and providers in other boroughs of New York City within their networks.

Enrollment

Initial enrollment begins with a 3-month grace period, whereby the consumer can try out the plan and transfer to another plan, if desired. This is followed by a 9-month lock-in period, during which time the enrollee must stay with the health plan, unless s/he has a "good cause" reason to disenroll. The total initial enrollment period is 12 months. In the 10th month of enrollment New York Medicaid CHOICE alerts the consumer, by mail, of his/her future enrollment options.

Since the implementation of the mandatory program, all eligible members of the eligible person's family (i.e. same Medicaid case) who join a plan must be enrolled into the same plan except in certain, limited circumstances.

• • Newborn Enrollment
  All newborn children not in an excluded category will be enrolled into the mother's health plan, effective from the first day of the child's month of birth. In fact, providers who are affiliated with a Medicaid MCO are required to accept a mother's MCO enrollment as sufficient proof of the newborn's enrollment in the mother's plan. The mother does not have to produce a Medicaid card or health plan card for the baby. Mothers who wish to have their child in a different health plan should contact New York Medicaid Choice and ask for a transfer packet for the child.

Accessing Health Care

When a consumer enrolls into a Medicaid managed care plan, s/he must use the providers in that health plan's network, except in limited circumstances. The two common exceptions are family planning services, and visits to the emergency room at non-participating hospitals for medical emergencies. The health plan is obligated to provide the enrollee with a list of participating providers by specialty and a list of facilities for the borough in which the enrollee resides.

The consumer may choose his/her own doctor, known as a primary care provider (PCP). If s/he does not choose a doctor, the plan is required to assign a PCP to the consumer. Many consumers will choose a health plan because their current PCP participates with that health plan. Health plans must offer choices of a least 3 PCPs per enrollee to choose from that are geographically and linguistically accessible.

Along with receiving a plan identification card from the health plan, enrollees retain their Medicaid benefit card to access those services covered by Medicaid, but not covered by the plan. For instance, members must continue to use their Medicaid card to purchase prescription and non-prescription drugs.

If the health plan does not provide dental services, members can use their Medicaid card and go to any Medicaid dentist for services. However, if the health plan does provide dental services, members must utilize in-network dentists.

Most of New York City's contracted health plans are capitated for family and reproductive health services. But whether or not the health plan provides family planning and reproductive health services, the member has "free access" to any Medicaid provider, in or out of the health plan's network without prior approval from the health plan or primary care provider.

What Are Some of the Benefits of Medicaid Managed Care

• • Enrollees in a health plan have a "medical home." Each enrollee has his/her own doctor, who knows his/her medical history and health concerns.
• • Every health plan has a provider network of hospitals, clinics, private practice physicians and specialists.
• • Health plans place a strong emphasis on preventive health care. The plans are also required to provide education and outreach for their enrollees and the communities they serve for the following public health concerns: asthma; smoking cessation; nutrition counseling; immunization; prenatal care and post-partum services; maternal and child health including developmental screening for children; family planning; lead poisoning prevention; tuberculosis; STD and HIV education; injury and violence prevention, domestic violence and mental health services.
• • Health plans have member service departments that assist enrollees with any concerns or problems - everything from getting health plan cards on-time - to receiving updated provider directories and help with choosing a doctor and navigating the health care system, to arranging for transportation to medical appointments (PDF).
• • Enrollees receive member services handbooks that describe the services of the health plan. Each enrollee is provided with orientation/information sessions that explain how to access health care, and how to file grievances.
• • Health plans must comply with the Americans with Disabilities Act.
• • Health plans have case management systems to meet the needs of their adult enrollees with certain chronic illnesses and physical or developmental disabilities.

Consumer Assistance

New York Medicaid CHOICE has a toll-free Consumer Help Line that is open Mon - Fri 8:30 AM to 8:00 PM and Saturdays 10:00 AM to 6:00 PM. Consumers can call 1-800-505-5678 for questions about Medicaid managed care and to arrange for individual counseling or to find out where the nearest group presentation is held.

Typical questions include:

• • Do I Have to Enroll into a Medicaid Managed Care Plan?
• • How Do I Choose a Primary Care Provider?
• • How Do I Transfer to Another Health Plan?
• • How Do I Apply for an Exemption or an Exclusion?

What About Problems with Medicaid Eligibility?

For problems or questions relating to Medicaid eligibility or Family Health Plus eligibility, consumers should call 311.