GIS 10 MA/011: Notification to Managed Care Plans of Low Birth Weight Babies

The purpose of this General Information System (GIS) message is to alert local social services districts to a new notification requirement regarding low birth weight babies. This pertains to all Medicaid eligible newborns, including those on Temporary Assistance cases.

General Managed Care policy dictates that a child born to a mother enrolled in Medicaid Managed Care or Family Health Plus will be automatically enrolled in that plan if the plan does business in that local district.

Managed Care policy further states that newborns with either an SSI/SSI-Related designation or who appear to meet the criteria for the SSI and SSI-Related category (SSI look alike) are excluded from managed care enrollment from age 0 to 6 months. This includes babies born weighing less than 1200 grams at birth. There is a Newborn Daily Update Report sent to districts that will show this designation as "Infant Less 1200 Grams". The upstate version is WMS Report WINR5225, and in New York City, it is WINRO796.

When local districts are informed by the above report or other means that a baby has been born with a low birth weight designation, and the mother is in a managed care plan, the local district must inform the health plan in writing (electronic means is acceptable) within 5 days of the discovery of the infant's status as excluded due to low birth weight. Health plans may not routinely receive this information from either the hospital or the parents, and may need to update their participating providers that these low birth weight babies will not receive plan coverage. They must access medical care from Medicaid fee-for-service providers.

Local districts are reminded that pre-enrolled infants meeting the criteria for SSI, SSI-Related, SSI look-alike, or birth weight of less than 1200 grams, must have his or her enrollment deleted. A restriction code of "90" should be input in the R/E subsystem for infants who are not coded in WMS as disabled to avoid future auto assignment.

Once an SSI or SSI-Related child has attained 6 months' of age he or she can be enrolled in a Medicaid plan, and will be required to in those counties that have implemented the mandatory program unless the child is otherwise exempt or excluded.

If a health plan has information regarding a low birth weight baby, they must inform local districts within five days of its discovery.

The Medicaid Managed Care/Family Health Plus contract will be updated to clarify this policy at its next amendment.