Home Care Payers
Managed Care is a term that is used to describe a health insurance plan or health care system that coordinates the provision, quality and cost of care for its enrolled members. In general, when you enroll in a managed care plan, you select a regular doctor, called a primary care practitioner (PCP), who will be responsible for coordinating your health care. Your PCP will refer you to specialists or other health care providers or procedures as necessary. It is usually required that you select health care providers from the managed care plan's network of professionals and hospitals. There are many different types of publically funded managed care programs in New York State serving residents in all age groups and various income levels.
Managed care plans pay the health care providers directly, so enrollees do not have to pay out-of-pocket for covered services or submit claim forms for care received from the plan's network of doctors. However, managed care plans can require co-pays paid directly to the provider at the time of service.
There are many different types of managed care plans. Most managed care plans certified by the New York State Department of Health offer health education classes or other programs to help enrollees stay healthy. Depending on the type of managed care plan you join, there may be additional services, such as transportation, available to you.
Download our resource list of Managed Care Plans in the 5 Boroughs of NYC [PDF] – We make every effort to keep these materials and links up-to-date. However, we do not guarantee the accuracy of this information. For an up-to-date list of Managed Long Term Care Programs click the following link: DOH Managed Care Plans List
Medicaid Managed Care
Medicaid Managed Care offers many New Yorkers a chance to choose a Medicaid health plan. Managed Care plans focus on preventive health care and provide enrollees with a medical home for themselves and their families.
*IMPORTANT INFORMATION FOR MEDICAID BENEFICIARIES*
Most Medicaid eligible people residing in mandatory counties are required to join a managed care health plan. Your Choice Matters or, for those people who receive SSI or are Certified Blind or Disabled, the You Have 90 Days to Choose A Health Plan brochure will explain to you how to choose a health plan, how health plans work, health plan services, who does not have to or cannot join a health plan, your rights and what to do if you are having a problem with your health plan.
To find out whether or not it is mandatory in your county to join a managed care health plan, view this Map of Counties provided by the Department of Health.
Managed care plans must tell their patients about the coverage offered, benefit packages, prior authorization rules, how to file grievances and utilization review appeals, reimbursement policies, how to change providers, get referrals, specialty care, any use of formularies and so forth. Enrollees also have a right to receive written notice of service and payment denials and of their Fair Hearing rights.
Most, but not all Medicaid beneficiaries in New York State must now join a Medicaid managed care plan. In regular Medicaid beneficiaries can go to any doctor who takes Medicaid. This is called "fee-for-service" because the doctor or provider gets a fee every time the beneficiary gets a service.
In Medicaid managed care, beneficiaries must join a managed care plan and can only see the doctors and other health providers in their plan's network. 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 hospitalizations. 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.
Beneficiaries must keep their regular Medicaid card which they will need to get prescriptions and other important benefits that are not covered (aka carved out) by their Medicaid managed care plan. See Appendix K of the Medicaid Managed Care Model Contract [PDF] for a list of which services are covered by the managed care plans and those that remain covered by regular Medicaid.
Disenrolling, Transferring and Exemptions
People who would like to disenroll or transfer out of their Medicaid managed care plan, or who think they should be exempt or excluded from Medicaid managed care, should call New York Medicaid Choice at: 1-800-505-5678 or the local department of social services. New York Medicaid Choice also has a designated telephone number for SSI beneficiaries: 1-800-774-4241; TTY: 1-888-329-1541.
Rights Fair Hearings and Plan Appeals
Managed care enrollees have the right to file grievances and appeals with their health plans, but they are not limited to the managed care appeals process. Model Contract, Sec. 25.2 [PDF]. Medicaid managed care enrollees are entitled to request a fair hearing whenever a benefit or service is reduced or denied by the plan. Enrollees are also entitled to request fair hearings if requested services are not provided with reasonable promptness.
However, if the denial is from a plan provider, the enrollee must first request that the plan review the provider's decision before they are entitled to request a fair hearing. If an enrollee requests a fair hearing because of a reduction in services, they also have aid-continuing rights. Model Contract, Sec. 25.4 [PDF].
If an enrollee chooses to pursue an appeal through their health plan, they may simultaneously request a fair hearing. If a plan's adverse decision is overturned during the managed care appeals process, the fair hearing request should be withdrawn because when external review and fair hearing decisions are conflicting, the fair hearing decision prevails. Model Contract, Sec. 26.3 [PDF].
You can use any of the following ways to request a Fair Hearing:
- By phone, call toll-free 1-800-342-3334
- By fax, 518-473-6735
- By internet, www.otda.state.ny.us/oah/forms.asp
- By mail, Fair Hearings, NYS Office of Temporary and Disability Assistance, P.O. Box1930, Albany, NY 12201
Managed Long Term Care
Managed long-term care (MLTC) helps people who are chronically ill or have disabilities and who need health and long-term care services, such as home care or adult day care, stay in their homes and communities as long as possible. The MLTC plan arranges and pays for a large selection of health and social services, and provides choice and flexibility in obtaining needed services from one place.
Download our resource, Managed Long Term Care Directory [PDF] – We make every effort to keep these materials and links up-to-date. However, we do not guarantee the accuracy of this information. For an up-to-date list of Managed Long Term Care Programs click the following link: DOH Managed Long Term Care Directory