Medicaid Managed Care (MMC) Overview:
- Overview is also available in Portable Document Format (PDF)
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):
An individual must be:
- 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 of 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 4/1/14, HIV phenotypic, virtual phenotypic and genotypic drug resistance tests and viral tropism testing | Covered through 3/31/14. HIV phenotypic, virtual phenotypic 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 palmitate (lnvega® Sustenna®). Abilify Maintena™ and olanzapine (Zyprexa® Relprevv™). | Hemophilia blood factors covered through MA FFS: also Risperidone 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 to 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. | on–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. | 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 (RHCP) | 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 |
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