Comparison of New York State Public Managed Care Programs

Updated: October 2012

Managed Care Provider Number Enrolled(October 2012) Population Enrolled Type of Managed Care Plan Health Plan Benefit Package Medicaid Fee- for- Service Pays for Some Services? How to Identify Enrollment/Plan Status Access to Health Plan Services
  • All patients have primary care practitioner (PCP).
  • Must use network provider (seek plan approval for exceptions).
  • Need plan/PCP referral/approval for most plan services.
Medicaid Managed Care 3,308,727 NYS residents with full Medicaid eligibility.
  • Most Medicaid covered adults, children & pregnant women.
  • Enrollment mandatory in all upstate counties and NYC as of November 2012.
  • Some Medicaid covered populations exempt (can enroll voluntarily) or excluded (cannot enroll). Individuals with Medicare are excluded (cannot enroll). Permanent residents of nursing homes currently excluded.
 HMOs & PHSPs1

94% eligibles are enrolled2.		 Comprehensive including in/outpatient hospital, physician, pharmacy, personal care, vision, some behavioral health, home health, home infusion, rehabilitation and other care provided by nursing homes, dental and orthodontics. Nursing home stays for members in permanent residence sometime in 2013.

Yes.

Pays for hospice, some behavioral health and, in some counties, transportation. Most behavioral health for SSI.

Use CIN # on patient plan card or CBIC "Benefit" card.
Check MEVS** Providers not enrolled in Medicaid check with plan.

Yes

No plan/PCP approval for services paid by Medicaid fee for service.
Case management available if plan determines it is needed. Starting in 2012, eligible enrollees may receive case management through a Health Home.
May offer disease management.
Family Health Plus 433,030
  • Uninsured adults ages 19 to 64.
  • Not eligible for Medicaid.
  • Gross Family Income:
  • Young adults (age 19 up to age 21) residing with parents and parents with children under age 21 in their households: 150% FPL.
  • Young adults (age 19 up to age 21) living alone and adults without children: 100% FPL.
  • U.S. Citizen, National, Native American or an individual with satisfactory immigration status.

In order to receive coverage, eligible individuals must enroll in a health plan.

 HMOs & PHSPs1

Comprehensive including in/outpatient hospital, physician, home health with benefit limits, pharmacy, home infusion, rehabilitation in nursing homes, behavioral health with benefit limits, vision, dental.

Family Planning Services covered by FFS if plan does not cover.

Use CIN # on patient plan card. Check MEVS**

Providers not enrolled in Medicaid check with plan.

Yes

Case management available if plan determines need.
May offer disease management programs. Starting in 2012, eligible enrollees may receive case management through a Health Home.

No plan/PCP approval for services paid by Medicaid fee for service.
Family Health Plus Premium Assistance Program 3,080
  • Adults ages 19 to 64.
  • Not eligible for Medicaid.
  • Gross Family Income and resource limits:
  • Young adults (age 19 up to age 21) residing with parents and parents with children under age 21 in their households: 150% FPL.
  • Young adults (age 19 up to age 21) living alone and adults without children: 100% FPL.
  • U.S. Citizen, National, Native American or an individual with satisfactory immigration status.

In order to receive coverage, eligible individuals must enroll in an employer sponsored health insurance plan that is deemed by NYS to be qualified and cost effective.  The FHPlus program will then pay for the individual’s share of the premium.

 Employer plan may be an HMO or private fee for service plan.

 Comprehensive including in/outpatient hospital, physician, home health with benefit limits, pharmacy, home infusion, rehabilitation in nursing homes, behavioral health, vision, dental in some plans. Services and supplies not covered by the employer plan, but otherwise covered by the FHPlus program are covered by Medicaid. Use ID on patient plan card.
Check with plan.
and
Use CIN# on CBIC “benefit” card.  Check MEVS**.		 No plan/PCP approval for services paid by Medicaid fee for service.
CHPlus 345,741
  • Uninsured children one month up to age 19.
  • Not eligible for Medicaid.
  • Premium subsidized for incomes at 160% to below 400% FPL. Full premium available for incomes above 400% FPL. No premium below 160%.
  • No citizenship requirements.
In order to receive coverage, eligible individuals must enroll in a health plan.		 HMOs
PHSPss[1]<		 Comprehensive - includes in/outpatient hospital, physician, behavioral health including in/outpatient mental health, alcohol and substance abuse. Benefit limits for home health (subject to annual limit of 40 visits in lieu of hospitalization). No Use ID on patient plan card. Check with plan. Yes
Case management available if plan determines needed. May offer disease management programs.
Managed Long Term Care
  • PACE
  • MAP
  • Partial Cap
 60,817
  • Enrollment is mandatory in NYC. Voluntary in remainder of State.
  • Able to live safely in the community upon enrollment.
  • In need of the long term care services of the plan for more than 120 days (nursing, therapy or aide services in the home; or adult day health care).
  • PACE: Adults 55 and older. Members must have Medicaid and/or Medicare and/or willingness to pay privately. Must disenroll from any facility or HCBS waiver program, Hospice, or any MCO before enrolling.
  • Medicaid Advantage Plus (MAP): Adults 18 and older.  Members must be dually-eligible for Medicaid and Medicare; must also be enrolled in a companion Medicare Advantage Plan.
  • Partial Cap MLTC: Adults18 and older (for most plans). Members must have Medicaid or willingness to pay privately (in some plans); can be enrolled in Medicare MCO concurrently but not Medicaid.
  • Medicaid Advantage Plus (MAP): Adults 18 and older. Members must be dually-eligible for Medicaid and Medicare; must also be enrolled in a companion Medicare Advantage Plan.
  • Partial Cap MLTC: Adults18 and older (for most plans). Members must have Medicaid or willingness to pay privately (in some plans); can be enrolled in Medicare MCO concurrently but not Medicaid.
  • MAP and Partial Cap:  May be in a nursing home upon enrollment if expected to be discharged.  Must disenroll from any HCBS waiver program; OMRDD day treatment; Hospice or any Medicaid MCO before enrolling.
  • MAP and Partial Cap: May be in a nursing home upon enrollment if expected to be discharged. Must disenroll from any HCBS waiver program; OMRDD day treatment; Hospice or any Medicaid MCO before enrolling.
 PACE Operates like HMO delivery system.
MAP
HMO
Partial Cap
HMO		 PACE
Comprehensive including Interdisciplinary Team Care Management, In/outpatient hospital, PCP and specialty physician, prescription and OTC drugs, dental, audiology, podiatry, optometry eyeglasses, rehabilitation, PT/OT/ST, adult day center, nursing home, home health care, personal care, home infusion, DME and transportation.
MAP Comprehensive including Care Management, Inpatient/outpatient hospital, PCP and specialty physician, mental health inpatient/outpatient and chemical dependency, DME, dental, audiology, podiatry, chiropractic, optometry/eyeglasses, transportation, prescription drugs, PT/OT/ST, nursing home, home health care, home infusion, adult day care, personal care, etc
Partial Cap
Care Management, Dental, Audiology, Podiatry, Optometry/Eyeglasses, Nursing Home, adult Day Health Care, PT/OT/ST, Home Health Care, personal care, DME & transportation.		 PACE
No
MAP
Yes. Limited special needs services and OTC pharmacy
Partial Cap
Yes. Pays for all in/outpatient hospital, physician, pharmacy, and all other Medicaid services not covered by the plan.		 Use CIN# on plan card or CBIC “benefit” card.   Check MEVS**. Yes
All patients have multidisciplinary case management teams.
Yes
All members have case managers.
Yes –PCP is not part of plan All members have care managers.
  • MAP and Partial Cap:  May be in a nursing home upon enrollment if expected to be discharged.  Must disenroll from any HCBS waiver program; OMRDD day treatment; Hospice or any Medicaid MCO before enrolling.
  • MAP and Partial Cap: May be in a nursing home upon enrollment if expected to be discharged. Must disenroll from any HCBS waiver program; OMRDD day treatment; Hospice or any Medicaid MCO before enrolling.
 Partial Cap
HMO		 Partial Cap
Care Management, Dental, Audiology, Podiatry, Optometry/Eyeglasses, Nursing Home, adult Day Health Care, PT/OT/ST, Home Health Care, personal care, DME & transportation.		 Partial Cap
Yes. Pays for all in/outpatient hospital, physician, pharmacy, and all other Medicaid services not covered by the plan.		 Yes –PCP is not part of plan All members have care managers.
Medicaid  Advantage 8,588
  • Enrollment is voluntary for eligible recipients.
  • Eligibility criteria:
    • Must have Medicare Part A and Part B coverage.
    • Must have full Medicaid coverage.
    • Must be 18 years of age or older.
    • Must otherwise not be excluded from enrolling in Medicaid managed care.
  • Must enroll in the same plan for both Medicare and Medicaid services.
 HMO
PHSPs2
Must have Federal approval to operate as a Medicare Plan.		 Comprehensive including all Medicare primary care, acute and post acute services including in/outpatient hospital, some mental health/inpatient chemical dependency, physician, home health, home infusion, rehabilitation services, prescription drugs Medicare and includes up to first 100 days nursing home. Yes.  Pays for prescription drugs not covered by Part D, long term care services including personal care services. Some services are carved out under Medicare  FFS.  Must disenroll if nursing home placement is permanent. Use patient’s CIN # on plan card or CBIC “benefit” card.
Check MEVS**.		 Yes for most services. No plan/PCP approval for services paid by Medicaid fee-for-service.
Case management if plan determines needed. May offer disease management programs
Healthy New York 171,600 (approx) Available to:
  • Small business owners providing health insurance to their employees and their families.
  • Working individuals whose employers do not provide health insurance.

Individuals may participate if:

  • they have been employed at some time during the past year or your spouse has been employed in the past year or you are a sole proprietor.
  • they have been without health insurance for 12 months or have lost coverage for certain reasons.
  • are ineligible for Medicare or employer coverage.
  • total household income is within the annual limits.

In order to receive coverage, eligible individuals must enroll in a health plan.

 HMO
 Comprehensive including acute care/primary services, in/out patient hospital, physician, preventive, lab x-ray, ER, diabetic supplies, post-hospital and post-surgical home health care, including PT and OT. 
Pharmacy optional. 
Not Covered: skilled nursing facility, hospice, OT, nursing home, rehabilitation, chiropractic care, chemical dependence treatment or mental health.		 NO. Use patient ID on patient’s card. Check with plan. Yes
As of January 1, 2012, all new enrollment in Healthy NY is required to enroll in a High Deductible Health Plan (HDHP).  A HDHP has a deductible amount that must be met before services (excluding preventive care) are covered.  The 2012 deductible amounts are $1200 for individuals and $2400 for families.  The 2013 amounts are $1250 for individuals and $2500 for families. 

1Prepaid Health Service Plans (PHSPs) - Enrollment limited to Medicaid, FHPlus, CHPlus eligible individuals.

2Prepaid Health Service Plans (PHSPs) - Enrollment limited to Medicaid, FHPlus, CHPlus eligible individuals.

** Methods of Determining Enrollee Status through MEVS.

MEVS is an acronym for the Medicaid Eligibility Verification System.

Four ways to access MEVS are: