Foster Care Cases Eligible to be Enrolled in Mainstream Medicaid Care (MMC)
- Checklist also available in Portable Document Format (PDF)
29-I Health Facilities should review the following checklist when seeking to newly enroll a child/youth in foster care in a Mainstream Medicaid Managed Care Plan or HIV Special Needs Plan; to transfer the enrollment to another plan; or disenroll the child/youth to Medicaid FFS.
New Enrollments:
- ☐ The case must haveactive Medicaid eligibility as of the date of the enrollment
- ☐ The child/youth cannot:
- ⮚ already be enrolled in a health plan
- ⮚ be placed outside of New York State
- ⮚ be placed by OMH, OASAS or OPWDD
- ⮚ have comprehensive third-party health insurance (TPHI), including Medicare, on their case; or
- ⮚ have Recipient Restriction Exclusion 90 or 46 on their case.
- ☐ For child/youth from NYC, the Client Identification Number (CIN) used to enroll must be a SERMA case (identifiable for eMedNY/WMS users as having a Case Number beginning with S, District 66, a Case Type of 40, and a CIN beginning with letters A through J)
Plan Transfers:
- ☐ The MMC plan transfer should be in the best interest of the child/youth
- ☐ Plan transfers are always prospective to the first of the next month. If a plan change is processed on 8/22/2021, the new enrollment effective date will be 9/1/2021.
- ☐ The case must haveactive Medicaid eligibility on the first of the next month
- ☐ The child/youth cannot:
- ⮚ be placed outside of New York State
- ⮚ have Recipient Restriction Exclusion 90 or 46 on their case
- ☐ For child/youth from NYC, the Client Identification Number (CIN) used to enroll must be a SERMA case (identifiable for eMedNY/WMS users as having a Case Number beginning with S, District 66, a Case Type of 40, and a CIN beginning with letters A through J)
Disenrollments
- ☐ Plan disenrollments are always prospective to the first of the next month, unless it is in the best interest of the child/youth to be retro-disenrolled to fee-for-service back to the first of the current month.
- ☐ The disenrollment must be due to an exclusion from MMC or otherwise in the best interest of the child/youth. Common exclusions include, but are not limited to, when the child/youth:
- ⮚ is to be placed outside of New York State
- ⮚ is to be placed by OMH, OASAS or OPWDD
- ⮚ has comprehensive third-party health insurance (TPHI), including Medicare; or
- ⮚ needs a service provider that accepts Medicaid but does not work with any MMC plans in the District of Fiscal Responsibility
Reminders
- 29-I facilities must check ePACES to confirm the case meets MMC enrollment criteria. Contact the LDSS if the child/youth's case appears to have incorrect or outdated information.
- The MMC plan selected for enrollment or transfer must operate in the District of Fiscal Responsibility. MMC plan selection includes evaluating which plan may be in the best interest of the child/youth, and considerations such as:
- plan choice of child/youth and parent/guardians, where appropriate
- current service needs and service provider locations
- identification of the child's current primary care provider (PCP)
- evaluation of the plans' provider network; and
- county and other placement arrangements for the child/youth.
- "Best interest" refers making an informed plan enrollment decision based on the needs of the child. The LDSS and 29-I Health Facility should consider the placement and care needs of the child, how best the child may retain or gain access to care, if the child/youth is being properly assessed, and how their needs can best be met. For example:
- If the child is expected to be out of the county (but within NYS) for a short time, it may be more disruptive to change their MMC plan
- If the child is currently receiving specialty services, check if their providers are participating with a proposed MMC plan. If that provider doesn't participate in any MMC plan, the child/youth receiving care f rom that provider should remain in FFS
- 29-I Health Facilities outside of NYC may contact the LDSS or New York Medicaid CHOICE to enroll, transfer or disenroll a child/youth in foster care and placed with their facility.
- 29-I Health Facilities in NYC may contact New York Medicaid CHOICE to enroll, transfer or disenroll a child/youth in foster care and placed with their facility.
- When calling New York Medicaid Choice, the 29-I Health Facility should provide the following information:
- their 3-digit authorization code;
- the 29-I Health Facility name and corporate address;
- the facility 8-digit MMIS ID number;
- the child/youth's inf ormation; and request to transfer the child/youth to another plan or disenroll to FFS.
- New enrollments are effective the f irst of the enrollment transaction month. For instance, if the enrollment is being processed on 7/20/2021, the enrollment date will be 7/1/2021.
