Medicaid Managed Care for People with HIV and AIDS Frequently Asked Questions
Medicaid Managed Care for People with HIV:
- What managed care options are available for people with Medicaid and HIV or AIDS?
- How has Medicaid managed care changed since the State began its program in 1997?
- How does Medicaid managed care change the way HIV+ individuals get their Medicaid benefits?
- How does someone make sure their care needs are met in a managed care plan?
- How does the current enrollment process work in New York City? Enrollment process means choosing a health plan.
- Will members of managed care plans and SNPs have to get referrals to see their HIV medical providers?
- Will people with HIV who enroll in managed care have to select new doctors?
- What services for people with HIV are carved-out of the Medicaid managed care benefit package?
- What if one of my providers leaves the plan while I am receiving care?
- If I join a New York City managed care plan, will I be able to continue seeing a provider who is located in a neighboring county?
- There is no HIV SNP serving Staten Island? Does this mean I cannot join a SNP?
Education and outreach to people with HIV:
- What efforts are being made to inform HIV providers about managed care?
- Information, support and outreach for people with HIV are important so there is no disruption is care. How does the state and city provide information to the community?
What managed care options are available for people with Medicaid and HIV or AIDS?
There are two options available. The first is a “mainstream managed care” plan. Under mainstream managed care, members get most of their Medicaid benefits from the managed care plan’s network of providers, hospitals, physicians, and clinics. The second option is a HIV Special Needs Plan (SNP), which is a health plan that provides the same benefits as a mainstream managed care plan as well as special services such as additional care coordination and support for people living with HIV/AIDS. If you live in New York City, there is a choice of HIV SNPs available. Only persons living with HIV/AIDS and their eligible dependents through age 20 can join an HIV SNP.
How has Medicaid managed care changed since the State began its program in 1997?
Since the mandatory Medicaid managed care program started in 1997, enrollment in managed care has grown dramatically to more than two million Medicaid beneficiaries. A lot of progress has been made toward improving the quality of and comprehensiveness of care in managed care plans. Managed care plans have increased the number of physicians who participate in their Medicaid programs. Member satisfaction has improved. Managed care plans have helped shift the focus of medical care to the primary care setting where a primary care provider works with specialists and other service providers to help keep members healthy. Medicaid managed care plans have shown that they can help members with chronic medical conditions and mental health service needs get access to services.
How does Medicaid managed care change the way HIV+ individuals get their Medicaid benefits?
HIV+ individuals have the same Medicaid benefits regardless of whether they are in Medicaid managed care or regular Medicaid. The main difference is that managed care members get most of their Medicaid benefits from the health plan’s network of providers, hospitals, physicians, and clinics.
Managed care plan members receive a health plan identification card and also keep their Medicaid card to receive certain benefits through regular Medicaid. These benefits, which are referred to as “carved out benefits,” include but are not limited to: prescriptions; certain HIV related labs tests; COBRA case management; AIDS adult day health care (ADHC); methadone maintenance treatment programs (MMTP) and selected substance abuse treatment and mental health services. The delivery of certain benefits like mental health and dental services may be different in HIV Special Needs Plans than in mainstream managed care.
All managed care plan members can get emergency services from any qualified provider
How does someone make sure their care needs are met in a managed care plan?
Once enrolled in a managed care plan, each person must choose a primary care provider who provides most medical care, coordinates health care services for the individual and makes referrals for both specialists and diagnostic tests, as necessary. In HIV Special Needs Plans, HIV experienced providers serve as primary care providers. In mainstream managed care, persons with a chronic disease like HIV/AIDS are given the opportunity to select a specialist (an HIV experienced provider) as their primary care physician.
People with HIV who want to continue to use the same doctor they currently use should learn which managed care plans their provider accepts before selecting a managed care plan. One can learn if a particular doctor is in a certain managed care plan by asking their provider or by calling the managed care plan or New York Medicaid CHOICE at 1-800-505-5678.
Managed care plans must allow a member who is receiving treatment for a condition at the time they join the plan to continue an ongoing course of treatment during a transitional period of up to 60 days or until the plan has put a treatment plan in place.
To assure that managed care plans meet the needs of persons living with HIV/AIDS, the plan must meet HIV treatment standards and care coordination requirements. The AIDS Institute regularly monitors each managed care plan’s activities to ensure it meets these standards.
How does the current enrollment process work in New York City? Enrollment process means choosing a health plan.
In New York City, enrollment activities are handled by New York Medicaid CHOICE. New York Medicaid CHOICE is responsible for mailing information on how to enroll in Medicaid managed care, and for helping Medicaid members choose a managed care plan that meets their needs.
Currently, eligible people with HIV can enroll in a managed care plan at any time by calling New York Medicaid CHOICE at 1-800-505-5678. New York Medicaid CHOICE will enroll the individual over the phone or send an enrollment packet in the mail. The enrollment packet contains a pre-printed form with the names of all available managed care plans, including HIV SNPs. Because enrollment of individuals with HIV/AIDS is now voluntary, individuals can request these enrollment materials to learn more about managed care options, but there is currently no requirement to select a plan within a specific timeframe.
To recap, there are several ways for an individual to get help with choosing a managed care plan. They can complete an application with a managed care plan representative, enroll over the telephone by calling New York Medicaid CHOICE or complete and mail an application to New York Medicaid CHOICE.
Will members of managed care plans and SNPs have to get referrals to see their HIV medical providers?
In an HIV SNP, the primary care provider (PCP) is an HIV-experienced provider. In mainstream managed care plans, members with HIV can choose to have their HIV-experienced medical provider serve as their PCP. In addition, managed care plans must allow Medicaid members to receive a “standing referral” for on-going and recurring care with a specialist. Each managed care plan has a member handbook to explain how to obtain these services.
Will people with HIV who enroll in managed care have to select new doctors?
People with HIV who enroll in managed care can keep the doctors they currently use if the doctors participate in the selected Medicaid managed care plan. Managed care plans and New York Medicaid CHOICE can help people with HIV identify which managed care plans their providers participate in. Most major HIV providers already participate in one or more mainstream managed care plans or Special Needs Plans (SNPs). Additionally providers may tell their patients which plans they participate with.
What services for people with HIV are carved-out of the Medicaid managed care benefit package?
Benefits that are currently carved out of the managed care benefit package would remain unchanged under mandatory enrollment. These include prescription drugs, COBRA case management, AIDS Adult Day Health Care Program, certain HIV laboratory tests, personal care and hospice services, and some mental health and substance abuse services; for example, Methadone Maintenance Treatment (MMTP). For these carved-out services, individuals go to providers that accept Medicaid and use their Medicaid Benefit card when getting these services. Their primary care provider or the health plan can assist in accessing these services.
What if one of my providers leaves the plan while I am receiving care
If a current member’s provider leaves the managed care plan during an on-going course of treatment, the plan may allow the doctor to continue treating the member for a ninety (90) day period of transition if the provider agrees to cooperate with the plan. For pregnant members in their second trimester, care can continue for 60 days post-partum if the member chooses.
If I join a New York City managed care plan, will I be able to continue seeing a provider who is located in a neighboring county?
Individuals who enroll in a Medicaid managed care plan may see providers who participate in the plan’s provider network. For example, a person who resides in the Bronx or Queens may choose a managed care plan that includes providers in Westchester County or Nassau County in its network. There are five New York City managed care plans that include Westchester County providers and five that include Long Island providers in their networks.
There is no HIV SNP serving Staten Island? Does this mean I cannot join a SNP?
No, people with HIV who reside on Staten Island 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 network's limitations.
- People with HIV may also choose to enroll in one of the nine mainstream managed care plans serving Staten Island residents. The mainstream plans may have both Staten Island providers and providers in other boroughs of New York City within their networks.
Education and outreach to people with HIV:
What efforts are being made to inform HIV providers about managed care?
Special efforts are being made to reach HIV health care provider groups to engage their support in assisting their patients and clients in understanding how managed care works and how enrollment in managed care changes how one gets health services. Medical providers have been asked to let their patients know which Medicaid managed care plans they participate in. A series of training sessions are being held for managed care plans and different provider groups to ensure there is no disruption of care for people with HIV who are enrolled in managed care.
Information, support and outreach for people with HIV are important so there is no disruption is care. How does the state and city provide information to the community?
The Department of Health, the AIDS Institute and New York City Department of Health and Mental Hygiene (CDOHMH) are providing community-based programs with information so that they can assist and support people with HIV. There are also specific trainings for HIV/AIDS Services Administration (HASA) workers and COBRA Case Management providers. Clinics, hospitals and individual doctors who treat HIV positive patients will have access to educational materials. Many HIV providers and community-based organizations already have experience working with the HIV SNPs.