Behavioral Health Transition to Managed Care

As part of Governor Andrew Cuomo´s efforts to "conduct a fundamental restructuring of the Medicaid program to achieve measurable improvement in health outcomes, sustainable cost control, and a more efficient administrative structure," the Governor appointed a Medicaid Redesign Team (MRT). The MRT created several work groups to review and provide recommendations in key areas, including behavioral health (BH).

In response to the BH work group´s recommendations, the adult transition to managed care was implemented October 1, 2015.

Qualified managed care organizations (MCO´s) throughout New York State provide comprehensive behavioral health services in the following ways:

  • Mainstream Medicaid Managed Care (MMC) Plan Changes Effective October 1, 2015:
    All adult recipients eligible for MMC (excludes Medicare recipients and certain other populations) receive the full physical and behavioral health benefit through managed care. Plans cover expanded behavioral health benefits.
    Consumers enrolled in an MMC whose behavioral health benefit was previously covered under Fee for Service Medicaid through SSI, currently receive these benefits through the MMC plan.
  • Health and Recovery Plans (HARP) and HIV Special Needs Plans (SNP):
    Adults enrolled in Medicaid and 21 years or older with select Serious Mental Illness (SMI) and Substance Use Disorder (SUD) diagnoses having serious behavioral health issues are eligible to enroll in HARP. These specialty lines of business operated by the MCO are available statewide. Individuals meeting the HARP eligibility criteria who are already enrolled in an HIV Special Needs Plan may remain enrolled in the current plan and receive the enhanced benefits of a HARP. HARPs and SNPs arrange for access to a benefit package of Home and Community Based Services (HCBS) for members who are determined eligible. HARPs and SNPs contract with Health Homes, or other State designated entities, to develop a person–centered care plan and provide care management for all services within the care plan, including the HCBS.

Adult Behavioral Health Managed Care Timeline

NYC Implementation

July 2015 – First Phase of HARP Enrollment Letters Distributed (see below for an explanation of initial enrollment process)

  • Enrollment notices will be issued to eligible individuals by NY Medicaid Choice in three phases:
    • Approximately 15,000 issued in July/August for October 1, 2015 enrollment
    • Approximately 25,000 issued in August/September for November 1, 2015 enrollment
    • Approximately 25,000 issued in September/October for December 1, 2015 enrollment

October 1, 2015 Medicaid Managed Care plans and HARPs implement expansion of non-HCBS behavioral health services for enrolled members

October 2015–January 2016 – HARP enrollment phased in

January 1, 2016 – BH HCBS become available for eligible individuals in HARPs and HIV SNPs

Rest of State Implementation

June 30, 2015 – RFQ distributed (with expedited application for NYC designated plans)

November 2015 – Conditional designation of plans

November 2015–March 2016 – Plan readiness review process

April 1, 2016 – First phase of HARP enrollment notices issued

July 1, 2016 – Medicaid Mainstream Managed Care plans and HARPs implement expansion of non-HCBS behavioral health services and phased HARP enrollment begins

October 1, 2016 – BH HCBS become available for eligible individuals in HARPs and HIV SNPs

Explanation of Initial Enrollment Process

  1. Individuals initially identified by the State as HARP eligible, who are already enrolled in an MCO whose parent company operates a HARP, will be passively enrolled in that plan´s affiliated HARP product after the 30 day opt out period.
  2. Individuals identified for passive enrollment will be contacted by the NYS Enrollment Broker.
  3. They will be given 30 days to opt out or choose to enroll in another HARP.
  4. Once enrolled in a HARP, members will be given 90 days to choose another HARP or return to a mainstream Medicaid managed care plan before they are locked into the HARP for 9 additional months (after which they are free to change plans at any time).
  5. Individuals initially identified as HARP eligible who are already enrolled in a Medicaid managed care plan without an affiliated HARP will not be passively enrolled. They will be notified of their HARP eligibility and referred to the NYS Enrollment Broker to assist with plan selection and enrollment in the plan that is right for them.
  6. HARP eligible individuals in a SNP will be able to receive HCBS services through the SNP. They will also be given the opportunity to enroll in a HARP. They will be notified of their HARP eligibility and referred to the NYS Enrollment Broker to help them decide which Plan is right for them.

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1 HARP eligibility criteria has been determined by the State. HARP eligibles cannot be dual enrolled (receiving both Medicare and Medicaid) or participating in a program with the Office for People With Development Disabilities (OPWDD)

In July 2015, DOH published a Special Edition Medicaid Update on the New York State Behavioral Health Transition to Managed Care.

The September 2015 Medicaid Update contains information for providers regarding HARP Enrollment Notices, billing guidance for behavioral health services, and additional information about pharmacy changes related to the NYC adult behavioral health transition to Medicaid managed care.

The June 2016 Medicaid Update contains information for providers regarding HARP Enrollment Notices, billing guidance for behavioral health services, and additional information about pharmacy changes related to the rest of state adult behavioral health transition to Medicaid managed care.