Integrated Care Plans for Dual Eligible New Yorkers

wheelchair

What does "Dual Eligible" mean?

Dual-eligible beneficiaries (Medicare "dual-eligibles" or "duals") refers to those who qualify for both Medicare and Medicaid benefits.
In the United States, approximately 9.2 million people are considered to be qualified for "dual-eligible" status.
(wikipedia.org)

Integrated Care Plans

An Integrated Care Plan is one that provides you with both your Medicaid and Medicare services from the same health plan. Integrated Care Plans are designed to help dual-eligible beneficiaries meet their health care needs within their own community, instead of going to a nursing home or other facility for care. There are three types of Integrated Care Plans in New York. Depending upon your care needs and whether you qualify as a dual-eligible, you may be eligible for an Integrated Care Plan.

Integrated Plans for dual-eligibles in need of LTSS (Long Term Services and Supports)

Both Medicaid Advantage Plus (MAP) and the Program of All Inclusive Care for the Elderly (PACE) will pay for all your Medicare health services at little to no additional cost to you and include benefits such as home care and other long term services and supports (LTSS) you may need. As a member of an Integrated Care Plan, you must use the plan’s network of doctors, although your existing doctor(s) may agree to participate with the plan.

  • MAP - Medicaid Advantage Plus
    • MAP provides Medicaid benefits including LTSS and Medicare benefits. Plans may also provide additional benefits such as transportation, home-delivered meals and over-the-counter (OTC) benefits such as vitamins, bandages, cold medicine, etc.
    • More information about MAP can be found in the dedicated section below.
  • PACE - Program of All-Inclusive Care for the Elderly
    • PACE provides all Medicaid LTSS and Medicare covered services through a team of health care professionals. This team helps decide what services are necessary to improve and maintain your health.
    • PACE offers you the option of receiving some services in your home or in its day center and on-site health clinic
    • Additional information about PACE can be found in the dedicated section below.

For additional enrollment information about the above plans visit New York Medicaid Choice.

Integrated Care Plans for dual-eligibles not in need of LTSS (Long Term Services and Supports)

  • IB-Dual - Integrated Benefits for Dual-Eligibles Program
    • This new program replaces the former Medicaid Advantage product. It provides a more complete set of benefits and services for those dual-eligible beneficiaries who do not require long term services and supports.
    • IB-Dual provides you with Medicaid and Medicare covered services through the same health plan.
    • IB-Dual allows members who are Medicare eligible to remain in their Mainstream Medicaid Managed Care health plan. You will receive both your Medicaid services and Medicare benefits through your current health plan as a dual-eligible beneficary.
    • Upon becoming Medicare eligible, you must enroll in the Medicare D-SNP (Dual Eligible Special Needs Plan) through the same health plan that is providing your Medicaid services to join the IB-Dual program.
    • Additional information about IB-Dual can be found in the dedicated section below.

Providing Integrated Care for Dual-Eligible New Yorkers

How to Join an Integrated Care Plan Network

Providers wishing to join a health plan´s network may contact the health plan directly to request application procedures and the minimum qualification requirements a provider must meet in order to be considered by the health plan. There is no requirement in New York State law that health plans accept any provider who wishes to join their network. However, health plans must maintain a network that is sufficient to deliver comprehensive services to their enrolled population. The Division of Health Plan Contracting and Oversight (DHPCO) reviews provider networks routinely to ensure enrollee access to health care. Contact DHPCO for problems encountered in obtaining application procedures.

Contracting with a Health Plan

The Division of Health Plan Contracting and Oversight (DHPCO) reviews HMO and IPA provider contracts to ensure that applicable laws and regulations are adhered to. However, the specific terms, services, compensation, risk arrangements, claims procedures, quality assurance requirements, etc. of the contracts are the purview of the contracting parties. Assistance with general contracting issues may be found by contacting professional associations or provider trade organizations.

Medicaid Managed Care Program

Medicaid managed care provides comprehensive health care services to enrollees. More specific information on enrollee eligibility and conditions of Medicaid coverage should be obtained by contacting the health plan and/or eMEDNY.


    What is Medicare?

    Medicare is a health insurance program that provides healthcare coverage to most people at age 65 and older and to disabled persons under age 65 regardless of income. The program has two parts, Medicare Part A (hospital insurance) and Part B (medical insurance).

    What is Medicare Advantage

    Medicare Advantage is a managed care program also known as Part C. This program that provides healthcare coverage to most people eligible for Medicare Part A and Part B. Eligible individuals may join this program if the choose to, and if available in the area where they live. The program offers coverage of Medicare services and may offer additional benefits such as vision, dental, hearing aids, gym memberships etc. Enrollees must use the plan’s doctors to receive their care, except in an emergency or urgent situation.

    What is a Medicaid?

    Medicaid provides health care to people with low or limited incomes to help them with health care costs not covered by Medicare.

    What is a D-SNP?

    A D-SNP (Dual Eligible Special Needs Plan) is a type of Medicare Advantage health plan that is designed to meet the specific needs of dual-elilgible beneficiaries. The health plan includes doctor, hospital, and prescription drug coverage and some health plans may also offer extra benefits. These extra benefits may include transportation, home delivered meals, over-the-counter (OTC) drugs, etc. Enrolling in a D-SNP will allow your health plan to coordinate all of your Medicare and Medicaid benefits, including your hospital, medical, prescription drug, and long term services and supports (LTSS). You will be eligible for enrollment into a D-SNP as long as you have both Medicare and Medicaid coverage and continue to live within the D-SNP's service area.

    Do I need to join a DSNP?

    If you wish to enroll in the MAP or IB-Dual Integrated Care Plans, you must join your health plan’s D-SNP. If you choose not to join these Integrated Care Plans, joining a D-SNP is not required, but still an option. Other options include other Medicare Advantage plans or Medicare Fee For Service (also known as Original Medicare). See below for how you can compare your choices.

    How can I get help comparing my Medicare plan choices?

    It’s important to find a plan that covers your doctor visits and prescription drugs. You can get help comparing your plan choices if you:

    • Contact your SHIP (State Health Insurance Assistance Program) at 1-800-701-0501. Representatives provide free, personalized health insurance counseling. SHIP counselors are not affiliated with any health plan.
    • Visit Medicare.gov Medicare’s web site has tools that can help you compare plans and answer your questions. Click “Find health & drug plans” to compare plans in your area.
    • Call 1-800-MEDICARE (1-800-633-4227). Tell them you got a letter saying you have Medicaid now and are going to be eligible for Medicare. Say that you want help with your Medicare choices. This toll-free helpline is available 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
    • Refer to your Medicare & You Handbook for a list of all Medicare health and prescription drug plans in your area. If you want to join one of these plans, you can call the plan to get information about their costs, rules, and coverage.

Consider MAP

The Medicaid Advantage Plus (MAP) plan is an integrated managed care plan that combines Medicaid and Medicare coverage offered through the same health care organization. When you join Medicaid Advantage Plus, you must also enroll in the plan’s Medicare Advantage Special Needs Plan product. The plan will take care of all your long term services and supports needs and other health services. You must choose one of the doctors from the plan to be your Primary Care Provider (PCP).

The plan will cover all Medicaid home care and long term services and supports. You will also get your Medicare services from the plan.

Who qualifies for MAP?

To enroll in the MAP plan, you must be 18 years or older, have full Medicaid and be eligible for Medicare Parts A and B. In addition, you must need at least 120 days or more of long term care services and supports. The MAP plan allows you to remain in the community in your own home while receiving your Medicaid and Medicare services.

What services can I get through MAP?

Services covered in the MAP plan include the following Medicaid and Medicare benefits:

  • Health Services at Your Home
    • Nurses
    • Home Health Aides
    • Physical Therapists
  • Personal Care
    • Help with bathing, dressing, and grocery shopping
  • Adult Day Health Care
  • Social Day Care
  • Nursing Home Care
  • Specialty Health
    • Audiology
    • Dental
    • Optometry
    • Podiatry
    • Physical Therapy
  • Other Services
    • Home-delivered meals
    • Personal emergency response
    • Transportation to medical appointments
  • Medicare Services
    • Doctor office visits
    • Specialty care
    • Clinic cisits, hospital stays
    • Mental health services
    • X-ray and other Radiology services
    • Chiropractic care
    • Medicare Part D drug benefits
    • Ambulance services

Note: MAP plans also offer over-the-counter (OTC) drug cards and may offer other benefits.

What service areas are MAP plans available in?

To join you must live in an area covered by a MAP plan. Not all areas of New York State have a MAP plan available, so you need to check with New York Medicaid Choice at (888) 401-6582 (TTY users: 1-888-329-1541) to find out if you live in a MAP service area.

Can you disenroll from MAP if it does not work for you?

If you enroll in MAP and then decide it is o’t the right program for you, you have the option to disenroll.

How can I get more information about MAP?

If you and your loved ones are considering MAP, the next step is to contact New York Medicaid Choice to discuss your interest and start the enrollment process. Remember, when you join the MAP plan, you must also enroll in a Medicare Advantage Special Needs Plan. You can contact the following for more information on your Medicare enrollment choices:

  • 1-800-MEDICARE (1-800-633-4227)
  • Medicare Rights Center

Consider PACE

The Program of All-inclusive Care for the Elderly (PACE) is, as its name indicates, a comprehensive managed care model designed to cover almost all an eligible individual’s health care needs in a single package. Serving individuals age 55 or older, PACE covers your Medicare, Medicaid and Part D drug services, based at a social day center that can provide a full health care clinic, meals, social activities and transportation. Fundamental to the PACE philosophy is keeping individuals independent and living in the community and includes a strong home health care component.

All your care and services are coordinated through a team of professionals that is focused on your needs and preferences.

Who qualifies for PACE?

As noted, you must be at least 55 years old. PACE services are completely covered for individuals with both Medicare and Medicaid, or who have Medicaid only. In addition, a community health assessment is needed to determine that you meet a certain level of care and that you will continue to need long term care supports and services (LTSS) for more than 120 days.

What services can you count on in PACE?

PACE services include the following:

  • A day center and clinic that offer social activities; nursing; physical, occupational, speech and recreational therapies; meals; nutritional counseling; social work and personal care.
  • Home health nursing and aide services
  • Medical care provided by a team led by your PACE physician working with you and your loved ones to design a complete care package.
  • Home health care and personal care.
  • Medicare Part D prescription drugs and over the counter supplies.
  • Social services.
  • Medical specialties, such as audiology, dentistry, optometry, podiatry and speech therapy.
  • Respite care for your loved ones.
  • End of life care for and pain management.
  • Emergency room and 24-hour phone coverage.
  • Telehealth.
  • Transportation to and from medical appointments.
  • Hospital and nursing home care when necessary.

What if I need different services?

Keeping you home and independent may require more than the usual medical services. Unique to the PACE model, the team can authorize many of the supplemental supports you may need, including:

  • Over-the-counter supplies and medications
  • Home modifications necessary to keep you safe and independent.
  • Pastoral and spiritual supports

Do PACE participants qualify for CDPAP?

As a PACE participant you are also eligible to participate in the Consumer Directed Personal Assistant Program (CDPAP) which may allow you to personally direct the hiring of a personal care aide.

CDPAP is a Medicaid option where the consumer has more control over who provides their care and how it is provided. Rather than an agency that manages the hiring and assigning of personal care aides, the consumer and his/her family directly manage these services.

Who decides what care and services I receive?

Ultimately, it’s you and your loved ones. To support you in making your health care decisions you will have a team of health care providers, led by your PACE primary care doctor. This team meets on a regular basis with you to develop a plan of care and evaluate your progress. It may also be possible for your current community physician to continue to follow your care at PACE.

What service areas are PACE plans available in?

To join you must live in an area covered by a PACE center. Not all areas of New York State have PACE, so you need to check with New York Medicaid Choice at (888) 401-6582 (TTY users: 1-888-329-1541) to find out if you live in a PACE service area.

What is a PACE Center?

Choosing PACE gives you the resources of both the PACE center and full service health clinic.

  • At the center, you can choose to come and benefit from maintenance therapy, social and recreational activities, meals, transportation, and personal care.
  • At the clinic, you can benefit from a complete, fully staffed health facility with doctors, nurses and therapists.

How did PACE start?

In considering if PACE is right for you, a little bit of history may help understanding the PACE model. PACE isn’t new, but the concept may be new to a lot of folks. The program was started in the 1970s on the West Coast by ethnic communities that were seeking an alternative to nursing home care for their loved ones. So, they designed a model that provides all the services of a nursing home but does so while keeping seniors at home in their communities. The popularity of the model is such that it soon spread across the country.

Can you disenroll from PACE if it doesn’t work for you?

PACE may not be for everyone. If you enroll in PACE and then decide it isn’t the right program for you, you can disenroll at any time, with no lock-in period.

How can I get more information about PACE?

If you and your loved ones are considering PACE, the next step is to contact New York Medicaid Choice to discuss your interest and start the process. A PACE representative will also want to meet with you and describe their program in detail, perhaps arrange a center visit and further help you make your decision.

Default Enrollment - new option effective April 1, 2021

Default Enrollment is a process that allows a Mainstream Medicaid Managed Care Plan (MMC) or Health and Recovery Plan (HARP) member to be enrolled into their health plan’s Medicare Dual Eligible Special Needs Plan (D-SNP) at the time they become Medicare eligible. To learn about Medicare D-SNPs, please see the FAQ section.

  • Members in need of LTSS will be enrolled into MAP through the Default Enrollment process.
    • LTSS Default Enrollment Notice: Long Term Care Services and Supports Member Notice for Default Enrollment into Medicare D-SNP and Medicaid Integrated Care Plan.
  • Members who do not need LTSS will be enrolled into the IB-Dual program through the Default Enrollment process.

Under Default Enrollment, you will receive your Medicaid and Medicare benefits through one health plan that will coordinate all of your services. To be eligible, you must be enrolled in a Mainstream Medicaid Managed Care Plan (MMC) or HARP through your health plan, that has been approved for Default Enrollment in your county. You may opt-out of Default Enrollment if you do not want to be enrolled into your health plan's Medicare D-SNP. For more information about health plans who have been approved for Default Enrollment please see the table below.

Plan Name H# / PBP# Product Type Service Area
Empire/HealthPlus H1732 (001) MMC/HARP Bronx, Kings, New York, Queens, Richmond and Nassau (6)
Empire/HealthPlus H1732 (002) MAP Bronx, Kings, New York, Queens, Richmond and Nassau (6)
Fidelis H5599 (001) MMC/HARP Albany, Allegany, Bronx, Broome, Cattaraugus, Cayuga, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Dutchess, Erie, Essex, Franklin, Fulton, Greene, Hamilton, Herkimer, Kings, Lewis, Montgomery, Nassau, New York, Niagara, Oneida, Onondaga, Orange, Orleans, Oswego, Otsego, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St. Lawrence, Steuben, Suffolk, Sullivan, Tioga, Ulster, Warren, Washington, Westchester, Wyoming, Yates (53)
Fidelis H5599 (003/008) MAP 003 - Bronx, Kings, New York, Queens, Richmond (5)
008 - Albany, Montgomery, Rensselaer, Schenectady (4)
Healthfirst H3359 (034) MAP Only Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk, Westchester, Orange, Sullivan, Rockland (11)
MetroPlus H0423 (001) MMC/HARP only Bronx, Kings, New York, Queens, Richmond (5)
United Healthcare H3387 (014) MMC/HARP only Albany, Bronx, Broome, Cayuga, Chautaugua, Chemung, Chenango, Clinton, Columbia, Dutchess, Erie, Essex, Genesee, Greene, Herkimer, Jefferson, Kings, Lewis, Livingston, Madison, Monroe, Nassau, New York, Niagara, Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Queens, Rensselaer, Richmond, Rockland, Schenectady, Seneca, Suffolk, Tioga, Ulster, Warren, Wayne, Westchester, Wyoming, Yates (44)

What is Default Enrollment?

Default Enrollment is a process to allow a Mainstream Medicaid Managed Care Plan (MMC) or Health and Recovery Plan (HARP) member to be enrolled into their health plan’s Medicare Dual Eligible Special Needs Plan (D-SNP) at the time they become eligible for Medicare.

How does Default Enrollment work?

Your health plan will send you a notice at least 60 days before you become eligible for Medicare. This notice will let you know that you will be enrolled into your health plan’s Medicare DSNP while remaining in your current Mainstream Medicaid Managed Care Plan (MMC) or Health and Recovery Plan (HARP). You do not have to take any action. The D-SNP coverage will take effect when your Medicare eligibility begins.

What if I do not want to be in the D-SNP? Can I opt-out of Default Enrollment?

You do not have to enroll in your plan’s D-SNP. You have other options for how to get your Medicare coverage. You may opt-out of Default Enrollment by calling your health plan or by sending a written opt-out request to your health plan. New York Medicaid Choice can connect you with your health plan to opt-out of the DSNP. Also, New York Medicaid Choice can help answer questions about your Medicaid managed care enrollment, since your Medicaid managed care options change when you become eligible for Medicare.

Resources and More Information on Integrated Care for Dual Eligible New Yorkers