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Section 2B.4 – How to Enroll in a Managed Care Plan
Last Updated: August 2012
In this section you will find...
How
to Enroll in a Managed Care Plan
Kind of Help Available to People on Medicaid and Family Health Plus (FHP)
New York Medicaid CHOICE
Contact a Managed Care Plan to Enroll
Information a Managed Care Plan Should Provide a Client When Enrolling
How to Join a Medicaid Managed Care Plan
When a Client Will Have to Join a Plan
What is Included in the NY Medicaid Choice Enrollment Packet
Changing Managed Care Plans
Other Languages that Client Speaks
Timeframe when Client’s Enrollment Becomes Effective
What is “Guaranteed Eligibility”?
Coverage During Travel
HOW TO ENROLL IN A MANAGED CARE PLAN1
Q. What kind of help is available to people on Medicaid and Family Health
Plus (FHP) in choosing a managed care plan?
A.
Selecting a managed care plan can be an overwhelming process. There are
several components to a managed care plan that a client needs to consider
when choosing a plan. An individual can get help from their Local Departments
of Social Services, the City of New York,2 from the managed care plans
themselves, and through community-based organizations (called Facilitated
Enrollers).
New York Medicaid CHOICE (NYMC) is a program that is run by MAXIMUS.
MAXIMUS is the enrollment broker than handles all enrollments and disenrollments around managed care plans for Medicaid and Family Health Plus.
Q. What does New York Medicaid CHOICE do?
A.
New York Medicaid CHOICE (NYMC) is a program that the State has set up
to help people enroll in managed care in most of New York State. In districts
where NYMC is not the enrollment broker, they will refer callers to their local
districts for assistance. Their toll-free phone number is 1-800-505-5678. They
help:
•
Enroll clients in the managed care plan that they choose
•
Auto-assign (select and enroll) beneficiaries who do not choose a plan
•
Provide individual advice
•
Confirm a client’s enrollment in a managed care plan
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•
Process transfers (people switching managed care
Disenrollments (returning to Medicaid Fee-for-Service)
•
Collect complaints about managed care plans
•
Process requests for exemptions and exclusions
•
Answer questions about any of the above
plans)
and
Face-to-face counseling: Anyone enrolling in managed care can ask for and receive
a free one-on-one, face-to-face counseling about choosing and using a managed care
plan. New York Medicaid CHOICE employs enrollment counselors to help Medicaid
and FHP recipients enroll in plans. Getting information in a one-on-one confidential
setting may be very helpful. Clients can find out how to arrange an individual
counseling session by calling the NY Medicaid CHOICE Helpline.
Group presentations: New York Medicaid CHOICE also offers group presentations
for people to learn more about managed care in general, as well as what their choices
are when choosing a plan. To find out the schedule for group presentations, call the
NY Medicaid CHOICE Helpline.
Counseling over the phone: People on Medicaid and FHP can call New York Medicaid
CHOICE’s Helpline to speak to a counselor who can help them understand their health
plan choices and how the program works more completely. This service should be
available in all languages.
Call the NY Medicaid CHOICE Helpline at 1-800-505-5678 for assistance.
Q. Can a client contact a managed care plan to enroll?
A.
Yes. Clients can call plans that they are interested in for information and to
enroll.
Q. What information should a managed care plan provide a client when he/
she is enrolling in a managed care plan?
A.
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Managed care plan representatives are required to provide the following
information to clients:
•
Provide a business card identifying the plan representative, the health
plan, and contact information for follow up questions (this information
may be available on brochures or other marketing materials);
•
Representatives must ask the client if he/she is already enrolled in a
Medicaid managed care plan and if so, stop marketing to them;
•
Give the client a copy of “What Managed Care Plans are Available in my
Neighborhood;”
•
Ask the client if he/she currently has a PCP that they would like to
continue to see and help the client determine if the provider participates
in the plan’s network;
•
A toll-free and TTY phone number for the plan;
•
The number for New York Medicaid CHOICE;
•
That the client has a choice among the available plans in his/her
neighborhood;
•
That the client will be able to choose from at least three Primary Care
Physicians (PCP) in the neighborhood;
•
That newborns will automatically be enrolled in the mother’s plan;
•
Information about Family Planning and Reproductive services, including:
what services are covered by the plan; what services can be obtained
via Fee for Service Medicaid; referrals are not needed for services; and
there is no cost to obtain services;
•
Inform clients that they are required to use Primary Care Physician and
in-network providers as the primary caregivers;
•
Inform clients that they have 90 days after enrollment to disenroll from
the plan without “good cause;”
•
Inform client that if they do not disenroll/change plans within the first
90 days of enrollment, he/she is “locked in” to that plan for the following
nine months (unless during that time, good cause can be shown);
•
Inform clients than upon enrollment they should receive a welcome
package or phone call from the plan to assess the client’s health care
need and to explain the services available; and
•
Inform clients what language assistance is available through the plan
(plan marketing representatives cannot market to an individual if he/
she does not speak their language).*
* Managed care plans are required to have materials available in 5 languages-English,
Spanish, Russian, Chinese, and Haitian Creole.
Q. How does a person join a Medicaid managed care plan?
A.
A person can join a Medicaid Managed Care plan by:
•
Signing up in person with a community-based organization’s facilitated
enroller, a representative of a managed care plan, or through New York
Medicaid CHOICE;
OR
•
Mailing in an enrollment form with the plan they want marked to:
New York Medicaid CHOICE
PO BOX 5009
New York, NY 10275-0935
Your client can use the Business Reply Mail envelope included in his/her packet.
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Clients also need to choose a primary care physician (PCP) within 30 days of joining
the managed care plan. If he/she does not choose one, the managed care plan will
assign a PCP to him/her.
Q. How will your client know when he/she will have to join a plan?3
A.
New Medicaid applicants must join a health plan as part of the application
process. Enrollees who have been on Medicaid but previously exempt or
excluded from joining a Medicaid Managed Care Plan will receive an enrollment
packet (white envelope) from New York Medicaid CHOICE. Family Health Plus
clients should choose a plan at the time of application. However, if the client
does not select a plan at time of application they can call New York Medicaid
Choice to enroll.
Your client has 30 days* (from the date stamped on the cover letter included in
the packet) to choose a managed care plan for him/herself and his/her family
(anyone listed in the letter).
New York Medicaid CHOICE will automatically assign him/her to a health plan
if the client does not pick one himself /herself. After the 30th day, New York
Medicaid CHOICE will send out a confirmation notice automatically assigning
the client to a plan. The notice will also indicate the name of the plan the client
has been assigned to and the starting date of the enrollment.
* Note: Special enrollment periods for SSI Individuals have been eliminated.
Q. What is in the New York Medicaid CHOICE enrollment packet that your
client will receive (THE WHITE ENVELOPE)?
A.
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New York Medicaid CHOICE will mail your client an enrollment packet that
contains:
•
A letter telling the client it is time to join a plan
•
A booklet explaining Medicaid managed care and a list of exemptions
and exclusions
•
A chart showing all the managed care plans serving the borough your
client lives in
•
A participating hospital list
•
A schedule showing the times and place where your client can attend a
community presentation about the New York Medicaid CHOICE program
•
A Managed Care Consumer’s Guide
•
A preprinted enrollment form
•
A stamped envelope addressed to New York Medicaid CHOICE
Q. What should a client do with the enrollment form in the packet?
A.
When a client receives the package he/she should choose a managed care plan
based on what his/her needs are.
Once your client has chosen a plan he/she should fill out the enrollment form
for all the family members who were listed on the letter. The form asks for each
person’s name, benefit card number, Social Security number, health plan and
PCP. Once the form is filled out, the client should sign and return the form to
New York Medicaid CHOICE.
The form must be returned to New York Medicaid CHOICE within 30 days of
the date stamped on the cover letter included in the packet. Your client can
also call NY Medicaid CHOICE at 1-800-505-5678 to enroll by phone, especially
if he/she thinks that the enrollment form will not be received in time if it is
mailed. If the client misses this deadline, he/she will be auto-assigned to a
plan by NY Medicaid CHOICE.
Q. Can clients change managed care plans?4
A.
If the client want to change plans that they chosen or been auto-assigned into,
he/she will have a 90-day grace period during which he/she can switch plans
(based on the date of the effective enrollment). After the 90-day grace period
ends, he/she is in a nine-month lock-in period. This will give the client a total
of one year in the plan; after one year is up, he/she is entitled to a new 90-day
grace period.
Q. What if your client speaks a language other than English?
A.
On the back of the envelope that the enrollment packet comes in, there is a list
of toll-free numbers to call if the client speaks a language other than English.
The client can get help over the phone in any language, directly through a NY
Medicaid CHOICE counselor or through a language line service. Materials are
available in five languages upon request: English, Spanish, Haitian Creole,
Russian and Chinese.
Q. How long will it take before your client’s enrollment is effective?
A.
About a week after the client sends in his/her enrollment form to New York
Medicaid CHOICE, he/she will receive a letter from New York Medicaid CHOICE
informing him/her of the effective date of enrollment. Next, the client will
receive a letter or a phone call from the new plan welcoming him/her to the
plan.
Q. What is “guaranteed eligibility”?5
A.
A client is guaranteed enrollment in a Medicaid managed care plan for the first
six months after his/her enrollment date, even if the client loses his or her
Medicaid eligibility during that period. During the six-month period, the client
will also continue to have prescription coverage and access to family planning
services through their plan or Medicaid fee-for-service.
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EXAMPLE
If your client joined a Medicaid managed care plan on January 1, and lost Medicaid
eligibility on February 3, the client would be able to receive plan benefits for another
five months, through June 30.
Advocate’s Tip: If a client needs assistance in choosing a managed care plan, make
sure you ask the following questions:
Ask...
Because the client will
want to know if the
managed care plan
will...
Information you should
know
Does the client already go to
a family doctor (PCP) that he/
she wants to keep seeing? A
pediatrician? A gynecologist?
...include that doctor,
gynecologist, and pediatrician in
its network.
Make sure the client’s PCP is
accepting new patients. If not,
see if the client wants to put
their name on a waiting list.
Does the client have a serious
illness or disability that requires
a doctor who specializes in that
kind of problem?
...include specialists in the kind
of care the client needs, or even
the specialist that the client
already uses.
A specialist can be the client’s
PCP if the specialist is willing
to take that role and accepting
new patients.
Does the client speak a
language other than English?
…have staff, doctors and
specialist that speak the client’s
language.
If the plan does not have
providers that speak the client’s
language they must provide
translation services.
...include doctors, pediatricians,
and hospitals that the client can
get to easily when feeling sick
or traveling with a sick child.
Most managed care plans
have a 24-hour medical advice
number for their members to
call if they need medical advice.
If the managed care plan does
not have a dedicated medical
advice number then it will be
the client’s PCP number.
How far is the client willing
and able to go to a doctor for
urgent care? When sick? For a
checkup? When his/her child is
sick?
...cover as many outpatient
mental health visits as the client
Will anyone in the client’s family needs in a year, and give the
need frequent outpatient mental client a choice of therapists.
health visits?
…cover the prescription
medication they need.
FHP: The Family Health Plus
benefit package includes
Outpatient Mental Health/
Chemical Dependency Services
up to a combined total of 60
outpatient visits per year when
medically necessary.
Does any family member need
to take prescription medicine
every day?
…cover their prescription
There are co-payments for
medication. Member services
or the plan website will have the prescriptions.
plan’s formulary (drug list).
Does the client and/or family
member have a serious illness
or disability that requires
frequent doctor visits and
specialty care?
…have a case manager that
can help coordinate all of the
client’s doctor appointments and
medical services.
They can also arrange
transportation services to
and from routine doctor’s
visits (Medicaid only). FHP
only provides emergency
transportation by ambulance.
Advocate’s Case Sample: Choosing A Health Plan
James received a white packet informing him that he has to choose a managed care
plan. He speaks Spanish and his English is very limited. He informs you that he has
severe arthritis; he goes to 3 different specialists and needs help controlling his
asthma.
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Q1. What information would you need to help James select a plan?
Q2. Below are 3 managed care plans that are available in James’ neighborhood.
Which plan may be the right choice for James?
Plan A
Plan B
Provides case management
services to help coordinate
doctor appointments and
transportation arrangements.
Has providers and specialists
that speak Russian, Haitian
Creole, Spanish and Italian.
No case management services.
Has two rheumatologist
specialists.
Provides services in only one
borough.
Plan C
Has limited providers and
specialists that provide services
in multiple languages. However,
can provide translation services
through a third party.
Has providers and specialist that
speak Russian, Haitian Creole,
Provides case management for
Spanish and Italian.
mental health services only.
Special Program: Asthma Is
Reduced (AIR) – This program
offers information and support
to individuals living with asthma
to help them understand the
disease and improve the quality
of their lives. An experienced
Case Manger coordinates
medical care and support
services.
Has doctors, hospitals and
clinics located in all 5 boroughs.
Has 20 Rheumatologist
specialists.
Special Program: Breathe-Free
– The Asthma “Breathe-Free”
Program helps members with
asthma recognize the early
signs of asthma and teaches
them how to manage their
condition. This is done through
education regarding signs/
symptoms of asthma, proper
medication technique and
importance of follow-up care.
Provides services in two
boroughs.
Sample Case Answers:
Q1. What information would you need to help James select a plan?
•
The name of all of the doctors and specialists he wants to keep seeing.
•
Type of specialists he needs.
•
How he travels to his appointments and whether he needs transportation
arrangements.
•
Will he need case management?
Q2. Which plan may be the right choice for James?
Plan B
After factoring in James’ doctors and specialists that he may want to keep, Plan B
may be the right choice for him because:
•
it has providers and specialists that speak his language
•
it may have providers closer to where he lives
•
it has a special program for members who have asthma
•
it provides case management for most of his medical needs
*As an advocate, you should not make the decision as to which plan your client
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should choose. Advocates should provide advice on options that best suit their clients’
medical needs. Clients should choose which plan is right for them.
Five Important Points to Remember About This Section:
1. If a client needs assistance with choosing a managed care plan, they
can receive assistance from their Local Department of Social Services,
the City of New York, from managed care plans, through Facilitated
Enrollers, through community-based organizations, or through New
York Medicaid CHOICE.
2. New York Medicaid CHOICE is the enrollment broker that handles all
enrollments and managed care plans and dis-enrollments for Medicaid
and Family Health Plus.
3. After joining a managed care plan, clients have 30 days to select a PCP.
If they do not, the managed care plan will assign a PCP to him/her.
4. Medicaid Clients Only: If the client did not select a plan at time of
application he/she will receive a white packet informing them that they
have 30 days to choose a managed care plan. If they do not, a plan will
be auto-assigned to him/her.
5. Choosing a managed care plan can be a very difficult process. As a client
or advocate, it is very important to ask questions before enrolling into a
managed care plan. For example: if the client already has a doctor (PCP
or specialist) that he/she wants to keep, make sure that doctor is part
of the plan’s network.
1
N.Y. State Dep’t of Health, Medicaid, Family Health Plus and HIV SNP Model Contract app. K (August,
2011), available at Section 15, http://www.health.ny.gov/health_care/managed_care/mltc/pdf/
mltc_contract.pdf
2
Health Insurance Services, “Are you looking for free or low cost health insurance for you and your
family?”, http://www.nyc.gov/html/doh/html/hca/ohis.shtml, last visited August 10, 2012.
3
Model Contract, Appendix H.
4
Model Contract, Section 6, paragraph 7.
5
Model Contract, Section 8, paragraph 9.
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