Medicaid Managed Care for People with HIV and AIDS Frequently Asked Questions

Medicaid Managed Care for People with HIV:

Answers

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 can join an HIV SNP.

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, clinics and pharmacies.

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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: 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 SNPs, 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. In some plans members can see a network specialist without a referral but should check with the plan.

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.

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 with that provider during a transitional period of up to 60 days or until the plan has put a treatment plan in place with a provider in the plan’s network. New members are encouraged to contact the plan to let them know about any ongoing treatment needs, including home care.

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.

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Do 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 request 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.

Do 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 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 include COBRA case management, AIDS Adult Day Health Care Program, certain HIV laboratory tests 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.

Once enrolled in a managed care plan, can a Medicaid beneficiary switch to another plan?

Enrollees may change health plans during the first 90 days (grace period) of enrollment. After the grace period, persons with HIV will be allowed to change from a mainstream plan (MCO) to an HIV SNP or from a SNP to SNP at any time. An HIV SNP member cannot transfer to a mainstream MCO after the grace period without good cause.

If I join a managed care plan, will I be able to continue seeing a provider 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.

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