Overview of Medicaid Managed Care (MMC)

  • Overview is also available in Portable Document Format

Medicaid Managed Care (MMC) Overview:

Managed Care is a general term used to describe any health insurance plan or system that coordinates care through a primary care practitioner or is otherwise structured to control quality, cost and utilization, focusing on preventive care.

Medicaid Managed Care (MMC) provides Medicaid state plan benefits to enrollees through a managed care delivery system comprised of Managed Care Organizations (MCOs).

MCO´s:
  • Authorized under Section 364–j of Social Services Law (SSL)
  • Contracts and pays the participating providers directly for services
  • Are paid a capitated rate (per member/per month) by NYS
  • Benefits consist of plan covered services and Medicaid Fee–For–Service carve–out services
NYS Medicaid Managed Care Plans (MMCP):
  • Are HMOs, PHSPs, or HIV SNPs
  • Certified under Article 44 of the Public Health Law by the Department of Health in conjunction with the Department of Financial Services
  • Qualified by the Department of Health to provide Medicaid services
  • Meet federal regulations at 42 CFR 438

Populations Eligible for Enrollment

Medicaid Managed Care Populations

All Eligible Persons who meet the criteria in Section 364–j of the SSL and/or New York State´s Operational Protocol for the Partnership Plan shall be eligible for Enrollment in the Contractor´s Medicaid Managed Care product.

Total MMC Enrollment as of July 2015:
Upstate:               1,823,516
New York City:     2,816,806
Total Enrolled:      4,640,322

Eligibility Requirements:

  • Most Medicaid eligible individuals are required to enroll in a MMC Plan unless otherwise exempt or excluded. Medicaid eligibility must be established first.
  • An exemption means that a consumer is not required to join a MMC Plan unless he or she so chooses.
  • Exemptions are outlined in NYS Social Services Law section 364–j(3)(d).
  • Some consumers remain excluded from MMC enrollment.
  • Under the Medicaid Redesign Team initiatives, most exemptions/exclusions are removed, and consumers will be required to enroll in MMC to obtain Medicaid covered services.

Covered Services:

  • MMC Plans are responsible for assuring enrollees have access to a comprehensive range of preventative, primary, specialty, ancillary and inpatient services through their provider networks.
  • See Appendix K Medicaid Managed Care Covered/Non–covered Services contained within the informational packet.

K.1

PREPAID BENEFIT PACKAGE

* See K.2 for Scope of Benefits
** No Medicaid fee –for–service wrap–around is available
Note: If cell is blank, there is no coverage.

* Covered Services MMC Non–SSI/Non–SSI Related MMC SSI/SSI – related MFFS FHPlus **
1. Inpatient Hospital Services Covered, unless admit date precedes Effective Date of Enrollment [see § 6.8 of this Agreement] Covered, unless admit date precedes Effective Date of Enrollment [see § 6.8 or this Agreement] Stay covered only when admit date precedes Effective Date of Enrollment [see § 6.8 of this Agreement] Covered, unless admit date precedes Effective Date of Enrollment [see § 6.8 of this Agreement]
2. Inpatient Stay Pending Alternate Level of Medical Care Covered Covered   Covered
3 Physician Services Covered Covered   Covered
4. Nurse Practitioner Services Covered Covered   Covered
5. Midwifery Services Covered Covered   Covered
6. Preventive Health Services Covered Covered   Covered
7. Second Medical/Surgical Opinion Covered Covered   Covered
8. Laboratory Services Covered. Effective 4/1/14, HIV phenotypic, virtual phenotypic and genotypic drug resistance tests and viral tropism testing Covered. Effective 4/1/I4, HIV phenotypic, virtual phenotypic and genotypic drug resistance tests and viral tropism testing Covered through 3/31/14. HIV phenotypic, virtual phcnotypic and genotypic drug resistance tests and viral tropism testing Covered
9. Radiology Services Covered Covered   Covered
10. Prescription and Non–Prescription (OTC) Drugs. Medical Supplies, and Enteral Formula Covered. Coverage excludes hemophilia blood factors. Covered. Coverage excludes hemophilia blood factors. Risperidone microspheres (Risperdal® Consta®.) paliperidone palmitatc (lnvcga® Sustenna®). Abilify Maintena ™ and olanzapinc (Zyprexa® Relprevv ™). Hemophilia blood factors covered through MA FFS: also, Rispcridone microspheres (Risperdal® Consta®). paliperidone palmitate (lnvega® Sustenna®). Abilify Maintena ™ and olanzapine (Zyprexa® Relprevv ™) covered through MA FFS for mainstream MMC SSI [see Appendix K.3. 2. b) xi) of this Agreement]. Covered. Coverage includes prescription drugs, insulin and diabetic supplies, smoking cessation agents, select OTCs, vitamins necessary to treat an illness or condition, hearing aid batteries and enteral formulae. Hemophilia blood factors covered through MA FFS.
11. Smoking Cessation Products Covered Covered   Covered
12. Rehabilitation Services Covered. Outpatient physical, occupational and speech therapy limited to 20 visits each per calendar year. Limits do not apply to Enrollees under age 21. Enrollees who are developmentally disabled, and Enrollees with traumatic brain injury. Covered. Outpatient physical, occupational and speech therapy limited to 20 visits each per calendar year. Limits do not apply to Enrollees under age 21. Enrollees who are developmentally disabled, and Enrollees with traumatic brain injury.   Covered for short term inpatient, and limited to 20 visits each per calendar year for outpatient PT, OT, and speech therapy.
13. EPSDT Services/Child Teen Health Program (C/THP) Covered Covered   Covered
14. Home Health Services Covered Covered   Covered for 40 visits in lieu of a skilled nursing facility stay or hospitalization, plus 2 post–partum home visits for high risk women
15. Private Duty Nursing Services Covered Covered   Not covered
16. Hospice Covered Covered   Covered
17. Emergency Services

Post–Stabilization Care Services (see also Appendix G of this Agreement)		 Covered

Covered		 Covered

Covered		   Covered

Covered
18. Foot Care Services Covered Covered   Covered
19. Eye Care and Low Vision Services Covered Covered   Covered
20. Durable Medical Equipment (DME) Covered Covered   Covered
21. Audiology, Hearing Aids Services & Products Covered Covered   Covered
22. Family Planning and Reproductive Health Services Covered if included in Contractor´s Benefit Package as per Appendix M of this Agreement. Covered if included in Contractor´s Benefit Package as per Appendix M of this Agreement. Covered pursuant t o Appendix C of Agreement. Covered if included in Contractor´s Benefit Package as per Appendix M of this Agreement or through the DTP Contractor.
23. Non–Emergency Transportation Covered if included in Contractor´s Benefit Package as per Appendix M of this Agreement until benefit is transferred 10 MFFS according to a phase –in schedule. Covered if included in Contractor´s Benefit Package as per Appendix M of this Agreement until benefit is transferred to MFFS according to a phase–in schedule. Covered if not included in Contractor´s Benefit Package. Benefit to be covered by MFFS according to a phase–in schedule. Not covered, except for transportation to C/THP services for 19 and 20–year olds. Benefit to be covered by MFFS according to a phase–in schedule.
24. Emergency Transportation Covered if included in Contractor´s Benefit Package as per Appendix M of this Agreement until benefit is transferred to MFFS according to a phase–in schedule. Covered if included in Contractor´s Benefit Package as per Appendix M of this Agreement until benefit is transferred to MFFS according to a phase–in schedule. Covered if not included in Contractor´s Benefit Package. Benefit to be covered by MFFS according to a phase –in schedule. Covered
25 . Dental and Orthodontic Services Covered. Covered. For Enrollees whose orthodontic treatment was prior approved before 10/1/12. MFFS will continue to cover through the duration of treatment and retention. Covered, if included in Contractor´s Benefit Package as per Appendix M of this Agreement, excluding orthodontia.
26. Court–Ordered Services Covered, pursuant to court order (see also § 10.9 of this Agreement). Covered, pursuant to court order (see also § 10.9 of this Agreement).   Covered, pursuant to court order (see also § 10.9 of this Agreement).
27. Prosthetic/Orthotic Services/Orthopedic Footwear Covered Covered   Covered, except for orthopedic shoes
28. Mental Health Services Covered   Covered for SSI Enrollees Covered subject to calendar year benefit limit of 30–days inpatient, 60 visits outpatient, combined with chemical dependency services.
29. Detoxification Services Covered Covered   Covered
30. Chemical Dependence Inpatient Rehabilitation and Treatment Services Covered subject to stop loss   Covered for SSI recipients Covered subject to calendar year benefit limit of 30–days combined with mental health services
31. Chemical Dependence Outpatient     Covered Covered subject to calendar year benefit limits of 60 visits combined with mental health services
32. Experimental and/or Investigational Treatment Covered on a case by case basis Covered on a case by case basis   Covered on a case by case basis
33. Renal Dialysis Covered Covered   Covered
34. Residential Health Care Facility (Nursing Home) Services (RHCF) Covered, except for Enrollees under age 21 in Long Term Placement Status. Covered, except for Enrollees under age 21 in Long Term Placement Status.   Covers only non–permanent rehabilitative stays.
35. Personal Care Services Covered. When only Level 1 services provided, limited to 8 hours per week. Covered. When only Level 1 services provided, limited to 8 hours per week.   Not covered
36. Personal Emergency Response System (PERS) Covered Covered   Not covered
37. Consumer Directed Personal Assistance Services Covered Covered   Not covered
38. Observation Services Covered Covered   Covered
39. Medical Social Services Covered only for those Enrollees transitioning from the LTHHCP and who received Medical Social Services while in the LTHHCP Covered only for those Enrollees transitioning from the LTHHCP and who received Medical Social Services while in the LTHHCP   Not covered
40. Home Delivered Meals Covered only for those Enrollees transitioning from the LTHHCP and who received Home Delivered Meals while in the LTHHCP Covered only for those Enrollees transitioning from the LTHHCP and who received Home Delivered Meals while in the LTHHCP   Not covered
41. Adult Day Health Care Covered Covered   Not Covered
42. AIDS Adult Day Health Care Covered Covered   Not Covered
43. Tuberculosis Directly Observed Therapy Covered Covered   Not Covered