Mandatory Managed Care Comes to L.I. SSI Recipients

Mandatory Managed Care is becoming a reality for many SSI recipients who, to date, have been exempt from having to enroll in a Medicaid Managed Care Plan. As part of this transition process, mandatory enrollment packets are being sent out to SSI recipients on Long Island.

In regular fee-for-service Medicaid, a recipient can go to any doctor, hospital or clinic that takes Medicaid. The doctor bills Medicaid, and Medicaid pays the bills as a third party payer. With Medicaid Managed Care, the recipient joins a plan that oversees their medical care. There are rules about which doctors the recipient can see within the plan and rules to access certain types of medical care. For example, the recipient chooses a Primary Care doctor, the doctors must be on the managed care plan list, and permission (referral) from the Primary Care doctor is usually necessary to see other doctors or to go to the hospital for non-emergency reasons. Managed care enrollees are entitled to all the services they received under regular Medicaid but there can be barriers such as prior authorization, exhausting in-network options, and utilization review. One of the benefits of Medicaid Managed Care is supposed to be case management services. The idea behind this type of case management is to assist in obtaining necessary medical care, assuring access and continuity of appropriate care, identifying health risks and developing treatment plans. But sometimes this “case management” ends up being more of a utilization review.

SSI recipients must enroll in a Plan within 90 days of receiving the notice or they will be randomly automatically assigned to a Plan. They have the right to switch Plans for any reason during the first 90 days of enrollment but after that they must stay in the Plan for 9 more months before a change can be made. But a change in Plans can be made anytime if there is a good reason. Call New York Medicaid CHOICE at 1-800-505-5678 to help with choosing or changing a Plan. Call 1-888-566-9799 for packet and enrollment forms.

Some SSI clients may be eligible for an exemption from the requirement to enroll in managed care enabling them to stay in the regular fee-for-service Medicaid program. There are also certain categories that are excluded from joining Managed Care (they cannot join managed care even if they want to).

Some bases for requesting an exemption from managed care include: managed care would be a barrier to accessing necessary medical services; or the client is enrolled in a specific program or facility, e.g. dual Medicaid/Medicare eligibles, Medicaid buy-in recipients and HIV + recipients are all exempt from joining managed care.  To request an exemption call New York Medicaid CHOICE at 1-800-505-5678 and ask to speak to an Exemption Counselor. Also, there is a special number for SSI recipients: 1 800 774 4241. A form will be sent out which must be returned to CHOICE and a decision should be received in a week or two. An additional 30 days is added to the auto assignment clock for SSI recipients whose needs and characteristics are similar to those in receipt of Medicaid waivers (available to individuals who are severely physically or developmentally disabled) if they are requesting exemptions prior to enrollment. If these “waiver look alikes” are under 18, they can be disenrolled from managed care and given 6 more months to document their need for an exemption. SSI recipients with lifelong conditions will have a durational exemption and will not be required to prove their need for an exemption each year. In all cases, a Fair Hearing is available to appeal the managed care exemption decision.

Some groups that are not allowed to join managed care (excluded) include those in a nursing home, state-operated psychiatric facility, or recipients with a Medicaid Spenddown. For more information on exempt and excluded groups, please see Medicaid Program Update and New York Expands Mandatory Managed Care To Include SSI Recipients.

Plans are responsible for continuing an ongoing course of treatment during a transitional period of up to 60 days for new enrollees with a life threatening condition or a degenerative or disabling disease or condition, to ensure continuity of care pending plan assessment and care plan development (including home health and private duty nursing). This means the managed care plans must cover new enrollees for care with their current providers, even if they are non-participating in the plan, pending plan assessment and care plan development.

Although persons with mental illness on SSI are not exempt from managed care, most mental health services are “carved out” of managed care meaning they will stay as covered fee-for-service by Medicaid. This would include therapy, case management, community residence restorative services.

Beware of aggressive marketing by Managed Care Plans. Pay special attention to specialists in the Plan, the quality of case management (Dept of Health work groups have been set up to deal with this), and continuity of care-eg does the plan cover the individual’s current providers? Note that regular Medicaid cards still cover prescriptions (unless Medicare Part D is involved), medical supplies, dental care if not covered by the plan, mental health and substance abuse services, and family planning.

The plan ID card is used for doctor visits, hospital stays, lab work, durable medical equipment, transportation and physical therapy. Remember that the administrative fair hearing appeal process is available to dispute any changes related to Medicaid or Medicaid Managed Care.