New Populations and Benefits Transitioning to Mainstream MMC

New Populations and Benefits Transitioning to Mainstream Medicaid Managed Care

Office of Health Insurance Programs
March 7, 2012

What Will Be Covered Today?

  • New Mandatory Populations in SFY 2012–13 with focus on April 2012 Populations
  • New Benefits Transitioning into Managed Care
  • Preparation Strategies to Minimize Disruption
  • Role of Enrollment Broker
  • Questions

MRT # 1458 – Expand Enrollment & Modify Benefit Package

  • The Medicaid Redesign Team proposal # 1458 focus was to streamline and expand enrollment into Medicaid managed care, including many previously exempt & excluded populations, and to integrate benefits.
    • MRT implementation began in August, 2011
    • Initiatives will continue over the next three years
    • Expansions will occur as program features are developed

New Populations in SFY 12–13

Effective 4/1/12 (contingent on CMS approval)

  • Individuals with end stage renal disease
  • Individuals receiving services through the Chronic Illness Demonstration Program
  • Homeless persons
  • Infants born weighing under 1200 grams or disabled under 6 months of age
  • Individuals with characteristics and needs similar to those receiving services through an HCBS/TBI, HCBS/CAH, LTHHCP, or ICF/DD

Effective 10/1/12

  • Residents of residential health care facilities – Nursing Homes

Effective 1/1/13

  • Long Term Home Health Care Program

Enrollment of New Populations

Previously Excluded or Exempt Non–Dual Population

4/1/12 (approx. 21,200)

  • Homeless         15,325
  • CIDP                    554
  • ESRD                  1486
  • Infants                  50–60 monthly estimate
  • Look–a–likes      3,864

10/1/12 Nursing Home Residents – approx. 9,444

1/1/13 Long Term Home Health Care Population – approx. 2,690

Population Expansion

  • For all the new populations
    • SDOH reviewed the care patterns of the populations and compiled provider lists
      • Renal disease, specialty neo–natal hospitals, homeless providers, etc.
    • Lists of providers sent to MCOs for contracting purposes to avoid care disruption
    • Providers should work with patients and encourage them to enroll in plans under contract.
    • Transitional Care Requirements will apply

New Population

  • Chronic Illness Demonstration
    • Program being phased out end of March, 2012
    • CIDP providers will assist clients in choosing a plan – many are affiliated with MCOs and Health Homes
  • Low Birth Weight Infants
    • Previously, these newborns would not be enrolled in a plan for the first 6 months of life
    • For infants born on or after 4/1/12, all babies will be enrolled into mother’s plan effective the DOB
    • This policy extends to previously excluded babies under 6 months of age with a disabling condition
  • Homeless
    • Have had several Meetings with Plans, Providers and Local Districts
    • Established 4 Workgroups
      • Case Management
      • Initial Assessment
      • Enrollment Phase In
      • Mailings and Residence
  • End Stage Renal Disease
    • Plans are currently managing the care for this population.
    • Networks are reviewed to ensure the major providers are participating
    • Transitional Care Policy
  • Individuals with characteristics and needs similar to those receiving services through an HCBS/TBI, HCBS/CAH, LTHHCP, or ICF/DD
    • This does NOT include those persons that the state has pre– coded as OPWDD
    • Clients have option of applying to be in a waiver, OR applying through OPWDD for designation to remain exempt.
  • Long Term Home Health Care Program
    • Non duals enrolled in the LTHHCP will have the option of enrolling into a MLTCPs or a mainstream Managed Care plans.

Changes to MMC Benefit Package SFY 12–13

  • Effective 1/1/12
    • Personal emergency response system (PERS)
  • Effective 7/1/12
    • Dental for MCOs currently not providing
  • Effective 9/1/12
    • Consumer Directed Personal Assistance Program (CDPAP)
  • Effective 10/1/12
    • Orthodontia
    • Residential health care facilities (Nursing Homes)

Enrollment of Homeless Population

Phase in of Homeless Population

  • NYC
    • Phase 1
      • FAMILIES
        • April – Bronx, Manhattan
        • May – Brooklyn, Queens, SI
    • Phase 2
        • June – Bronx, Manhattan
        • July – Brooklyn, Queens, SI
    • Phase 3
        • August/September – All boroughs
  • Upstate
    • Prior to 4/1/12, LDSS had option to exempt, exclude, or mandatorily enroll homeless
    • Upon survey of upstate LDSS, many homeless currently enrolled
    • Beginning 4/1, all upstate districts will begin enrolling all homeless at next contact, recertification or other case change
  • Statewide – If no address or way to reach consumer, enrollment will be delayed until valid address received

Education and Outreach

  • Local Districts
    • Posters in community, working with community organizations, etc
  • Providers
    • NYC staff training of providers, Medicaid Update article, webinar
  • Shelters
    • Training from NYC/HRA staff, upstate outreach by LDSS
  • Health Homes
    • State work with Health Homes to assist in selecting the right plan

Identifying the Homeless

  • NYC
    • Department of Homeless Services social service directors/shelter directors will receive list of shelter residents targeted for a mandatory mailing for "heads up"
    • NY Medicaid Choice enrollment packets will be mailed directly to families
    • For singles and couples, enrollment packets will be batched by social services director/shelter director for distribution to the residents
    • Every shelter as well as health plan will have designated staff to assist with enrollment referrals, education, and outreach, as well as post enrollment plan information
    • List is being compiled to disseminate to the shelters and health plans
  • Upstate
    • Beginning 4/1, all upstate districts will reach out to homeless through
      • providers
      • Motels, shelters
      • CBO´s, soup kitchens, etc
      • LDSS staff in contact with recipients e.g. Food Stamps, Temporary Assistance, Services, etc

Homeless Provider Network


MCOs are required to contract with a minimum of two federally designated homeless providers (330 H FQHC) per county where available.

  • The providers are the Federally Qualified Health Centers (FQHC). There is a subset of FQHCs that are federally designated as Homeless providers.
  • There are 14 FQHCs (330H).
    • 12 in NYC
    • 1 in Westchester and
    • 1 in Putnam County


  • The majority of NYC MCOs have contracts with at least 2 FQHC (330H) in each borough and many already include more than 2.
  • Upstate MCOs have contracts with FQHCs in all counties where available.
  • MCOs are being notified of the need to add additional providers if necessary.
  • NYC MCOs have also reported that they have additional contracts pending with the federally designated homeless providers.

PCP Assignment

  • MCO will facilitate changing member´s PCP assignment to participating shelter provider upon member request
  • MCO will facilitate changing member´s PCP assignment to a PCP closer to shelter location upon member request
  • MCO will work with FE, local district, or Maximus to disenroll and enroll member into another plan in order to continue relationship with provider.

Provision of Initial Assessment

  • Local Districts and shelters have arrangements with providers to provide the initial assessment for adult clients.
  • Many providers will now be affiliated with plans and will be able to continue to provide the initial assessment to members enrolled in plans which provider participates.
  • Non participating providers will request authorization from plans to conduct assessments and/or treat the population to avoid additional obstacles for consumers.
  • Providers will use participating labs and pharmacies.
  • Additional follow–up care will be referred to a plan provider or will be authorized by the plan.
  • If provider wants to continue to treat the patient and the patient wants to receive care from the provider, member will be encouraged to dis–enroll and enroll in plan that contracts with the provider.

Case Management

  • Focus on getting the homeless into case management programs, as needed.
  • Identify the homeless population for plans to allow them to determine the level of engagement needed.
  • Allow referrals from local districts, providers and shelters for internal and external (Health Home) case management as needed.
  • Plans will request approval from the State for specific clients to receive Health Home Services as needed.
  • Internal Case management programs and external case management programs will compliment not duplicate efforts
  • Contact information from plans, providers and shelters will be shared to foster better communication

MCO General Responsibilities

  • Determine medical necessity and authorize follow–up care.
  • MCO will either authorize care or arrange transportation and referral to the network provider.
  • Educate member service staff on issues pertaining to the Homeless population so that they can be responsive to providers and consumers.
  • MCO will not unreasonably withhold authorization for initial assessments and follow–up care
  • MCO will give authorization on a timely basis to allow for the provision of services to this population.
  • Reimburse providers for services rendered to the homeless population.
  • Operate timely/accessible complaint/appeal procedures, including enrollee notices;

Overview of Enrollment Process


  • Beginning 4/1/12, populations that self identified and were approved as exempt with NYMedicaid CHOICE will receive a notice informing them that their exemption/exclusion is going away and they have 30 days to apply for another exemption if appropriate.
  • All new mandatory populations will receive a mandatory notice advising them that it is time to choose a health plan
    • NYMedicaid CHOICE for many counties
      • NYMedicaid CHOICE (NYMC) is the enrollment broker for the City of New York and most upstate counties
    • County DSS for non–NYMedicaid CHOICE counties
  • A consumer can contact NYMC with any questions or concerns or to enroll by calling 1–800–505–5678
  • Consumers can enroll over the phone by contacting the LDSS or NYMedicaid CHOICE (NYMC will accept phone enrollments in any county)

Mandatory Enrollment

  • Consumers who are targeted for enrollment or are eligible for enrollment upon recertification will have 30 days to choose a health plan
  • 90 day grace period
  • Lock in for 9 months unless have a good cause reason
  • Persons applying for Medicaid are required to chose a Health plan when filling out their Medicaid Application

Mandatory Packet

  • Cover letter
  • Brochure
  • Health Plan list
  • Enrollment form
  • Business reply envelope
  • Regional Consumer Guide

NYS Medicaid Managed Care

map of all counties


  • The provider–client relationship is very important and consumers are encouraged to speak to their current provider and find out what plans they currently participate with.
  • If the client wishes, he/she can also call New York Medicaid CHOICE at 1–800–505–5678 who can verify what plans their provider participates with.

Assistance With Plan Choice

NYMC representatives are capable of locating a provider by entering one or more of the following characteristics to perform a search on HCS:

  • provider name or license number,
  • site name, zip code, primary designation,
  • primary specialty, or
  • language

LDSS managed care staff have plan provider information available to assist with finding a provider and plan choice

Consumer Representation

When a person other than the consumer contacts a local district or New York Medicaid CHOICE – verbal or written authorization from the consumer is required

  • Verbal: consumer identifies representative to the counselor
  • Written: consumer submits a letter or consent form designating a person as their representative:
    • Date, duration of request
    • Consumer CIN/SSN
    • Representative´s name, clinic or hospital association
    • Consumer´s signature
  • NOTE: Translators are not considered representatives and employees of health plans contracted by the SDOH cannot serve as representatives of consumers unless they are members of the Medicaid case