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New York Expands Mandatory Medicaid Managed Care to Include SSI Recipients

October 1, 2006

Author: Trilby de Jung

On September 29, 2006, New York State received formal approval from the Center for Medicare and Medicaid Services (CMS) for extension of its Medicaid Managed Care program and implementation of a new Federal-State Health Reform Partnership. The terms and conditions for these two waiver programs lays out a game plan for Medicaid reform in New York over the next five years, which includes significant expansion of mandatory Managed Care for persons receiving Supplemental Security Income (SSI). For copies of the waiver documents, visit: http://www.cms.hhs.gov/ MedicaidStWaivProgDemoPGI/MWDL/list.asp.

By October 31, 2006, all 28 New York counties that currently mandate managed care for Medicaid recipients must expand the mandate to include SSI recipients and those over 65 years of age. For a list of which counties are mandatory, voluntary or not currently offering Medicaid managed care plans.

In addition, Governor Pataki and the New York State legislature cleared the way for significant expansion of mandatory Medicaid managed care into more upstate counties during this past legislative session. A statutory change was enacted that lowers the threshold for rural counties that wish to enter the managed care arena. While prior law required counties to offer the choice of at least two managed care plans before mandating enrollment, the law now allows rural counties to mandate enrollment even where only one managed care plan is available to beneficiaries. See SSL § 364-j(4)(b).

Thus, whether you are in an upstate county, on Long Island, or in one of the boroughs of New York City, increasing numbers of your clients are likely be confronted with the challenge of navigating managed care in the near future. Your clients’ experiences will undoubtedly vary depending on the local landscape. Enrollment in Medicaid managed care may represent a loss of access to services for some clients and/or an improvement in care coordination for others.

Whether you are advocating to maintain traditional fee-for-service Medicaid for your client, or trying to help a client enroll in managed care, you should be aware that SSL § 364-j provides some exemptions for those Medicaid recipients who do not wish to join managed care plans. Section 364-j also excludes certain Medicaid recipients from joining managed care even if they want to.

Exemptions Based on Barriers to Accessing Care

Section 364-j(3)(b) provides four basic exemptions that are available to Medicaid recipients who will experience managed care as a barrier to accessing services. Recipients must prove that:

A managed care provider is not geographically accessible, or
If pregnant, their provider is not with a managed care plan, or
They have a chronic medical condition and are being treated by a provider outside the plan, or
They cannot be served by a managed care provider due to a language barrier.

Exemptions Based on Enrollment in a Specific Program

Section 364-j(3)(c) lists six categories of recipients who can claim an exemption from mandatory Medicaid managed care because of their enrollment in, or eligibility for, specified programs or facilities. Native Americans are also included in the following § 364-j(3)(c) list of persons eligible for exemptions:

Those who live in an alcohol/substance abuse program or a facility for the mentally retarded;
Those who are mentally retarded and get care from an intermediate care facility (or have similar health needs);
Those who have a developmental or physical disability and are in a special treatment program
Those in the “care-at-home” program (or have similar health needs)
Native Americans
Those dually eligible for Medicaid and Medicare and not enrolled in a Medicare TEFRA plan (Tax Equity and Fiscal Responsibility Act of 1982);
Those enrolled in the Medicaid Buy-in Program for Working People with Disabilities (MBI-WPD) and not required to pay a premium.

Exemptions that can be Lifted by State Commissioners

Section 364-j(3)(g) specifies certain groups of recipients as exempt from mandatory enrollment, but only until the Commissioner of Health (and in some cases the Commissioner of Mental Health) determines that the local managed care program is ready to accommodate them. These groups include:

Those dually eligible for Medicaid and Medicare and enrolled in a TEFRA plan;
SSI recipients (Note: under the new waivers, this exemption will be lifted in all 28 counties that currently mandate Medicaid managed care for other Medicaid recipients);
HIV positive recipients;
Adults with serious and persistent mental illness and children with serious emotional disturbances.

Exclusions from Medicaid Managed Care

Section 364-j(3)(d) provides a list of Medicaid recipients who are not allowed to join Medicaid managed care plans even if they would like to. This group includes:

Those in foster care;
Those eligible for Medicaid with a spend down,
Those in a nursing home, hospice, long term home health care program, state-operated psychiatric facility or residential treatment facility for children;
Those receiving Medicare and in a long term care program;
Infants living with a mother in jail;
Those receiving Medicaid for less than 6 months (i.e. Emergency Medicaid);
Those using Medicaid only for tuberculosis related services
Blind or disabled children who live away from their parents;
Those receiving hospice services;
Those in Medicaid’s Restricted Recipient program;
Those with other insurance;
Infants weighing less than or equal to 1200 grams at birth and other infants meeting the SSI-related categories;
Those in the MBI-WPD program and subject to a monthly premium.

In addition, Section 364-j(3)(f) excludes two groups from participating in Medicaid managed care unless the local district permits them to participate:

Individuals or families living in a shelter and/or homeless;
Foster care children in the care of the district.

What Will Medicaid Managed Care Look Like for SSI Recipients?

The short answer is, we don’t know yet. New York City is the first to experience mandatory enrollment of SSI recipients – the Department of Health lifted the exemption for the SSI population there in November of 2005. Mandatory enrollment packets have been randomly mailed to 2500 SSI recipients each month since November. All SSI recipients in NYC also received a letter informing them that they would soon be required to join a managed care plan and encouraging them to voluntarily enroll.

In NYC, recipients will have 90 days from the date they receive their mandatory enrollment materials to choose a plan or apply for an exemption under a different category. After 90 days, they are subject to random auto-assignment to a health plan. The first auto-assignments for SSI recipients in NYC began April 1, 2006.

Once enrolled in a plan Medicaid recipients have 90 days to change plans before they are locked-in for the following 9 months, unless they can establish good cause to switch plans. After the lock in period has ended, recipients can change plans for any reason. SSL § 364-j(4)(f). See also, Medicaid Managed Care Model Contract, Appendix K, available at http://www.health.state.ny.us/health_care/managed_care/providers/index.htm.

Advocates for the disabled have articulated several concerns about the expansion of Medicaid managed care to include the SSI population. First, according to research done by the Center for Independence for the Disabled (CIDNY) and Legal Aid in New York City, many managed care plans have yet to achieve full compliance with the Americans with Disabilities Act. Thus, their systems may present significant barriers for many SSI recipients.

Second, many managed care plans employ aggressive marketing practices, which can be confusing at best and misleading at worst. Another significant concern is that access to specialists may be restricted under managed care plans, which would lower the quality of care available to those with chronic, complex conditions. Finally, the standards for case management services within Medicaid managed care are far from clear. If case managers dependent on Medicaid fee-for-service reimbursement are no longer available to those with complicated health needs, managed care plans and their provider networks may be ill-equipped to provide a meaningful alternative.

Although SSI recipients can still claim other exemptions from enrollment in Managed Care (see Exemptions referenced earlier in this article), explanation of these rights is only one of many topics covered in the twelve page mandatory enrollment packets that they receive by mail. Outreach and education is sorely needed to make sure clients are aware that they may still have the option to receive health care under fee-for-service Medicaid. And advocacy will likely be needed to ensure that exemptions are granted when appropriate.

In Summary

Be on the look-out for changes in Medicaid service delivery in your county and neighboring areas. Scrutinize marketing materials and ask questions about access to plan services for those with disabilities. If your client receives a mailing from the county or state about mandatory enrollment in managed care, remember to check for applicable exemptions and let your client know his or her options.

Information about your clients’ rights within managed care, including the right to specialty care and the right to utilization reviews and appeals, is available under the Managed Care section of the Health Care Resources page on the Online Resources Center. Visit: http://onlineresources.wnylc.net/healthcare/health_care.asp. Many thanks to Lisa Sbrana of the Legal Aid Society in New York City for the use of her excellent outline on Medicaid Managed Care, which supplied much of the information presented in this article.