Statement of Standards

Assuring that PLWA receive quality care if mandated into Medicaid Managed Care   

What:  Historically, Medicaid beneficiaries with HIV/AIDS have been exempt from having to enroll in Medicaid managed care (MMC.)  Currently, New York State is considering requiring people living with HIV and AIDS to join MMC.  

We have strong concerns about the use of managed care as a universal approach for the delivery of care for all Medicaid beneficiaries, especially for those with complex health care needs like HIV and AIDS. We are opposed to limiting the choice people living with HIV and AIDS currently have to either join a MMC or HIV Special Needs Plan or retain fee-for-service Medicaid coverage.   

We urge the State Department of Health to consider the following recommendations, based on the experience of other disabled and chronically ill populations, prior to mandating a new chronically ill populations into MMC.

Recommendation: Prior to implement mandatory managed care enrollment we ask that the State Department of Health establish a Task Group to gauge evidence of improved health outcomes and assure that quality of care is being routinely provided to people living with HIV and AIDS who are currently enrolled in mainstream Medicaid managed care.  Additionally, the HIV/AIDS Task Group should also assess the needs of the HIV/AIDS population, suggest program features to help meet these needs, and evaluate readiness of plans to absorb this population.

STANDARDS SDOH SHOULD MEET PRIOR TO HIV/AIDS ENROLLMENT:

1. Evaluation of the experiences of other disabled populations in MMC:

SDOH should conduct focus groups of newly enrolled SSI recipients to evaluate access to and quality of care from recipients perspective (a recently release SDOH survey  of SSI recipients got less than 10 % response rate. ) Focus groups should include analysis of reasons for voluntary disenrollment, complaints and grievances.

2. Transparency in policies and practices: 

We request that the State Department of Health inform the health advocacy community of its plans and be open to input and advice from health advocates who work with disabled and Medicaid recipients with HIV/AIDS and aware of their complex health issues and needs.  

3. Capacity of Plan Networks and Access to Providers: 

SDOH must assure that HIV/AIDS providers are adequately represented in plan provider networks in the clinical settings where they currently provide a variety of different medical services in a coordinated setting (i.e. all providers in same clinic should accept same plan!) HIV/AIDS specialists must be available to take new MMC plan patients.

4. Pre-Enrollment:

         a. Widespread and alternative forms of outreach and training to health plans, providers, consumers, advocates and CBOs who work with the Medicaid population is required.  This should include ongoing assistance and outreach for  plan navigation and access to services and benefits after enrollment.  Provider outreach including letters to providers explaining a patient 's enrollment should be individualized to the extent possible and should go to all known providers, including primary care provider, specialists and clinics.

         b.  Automatic exemptions/exclusions should be processed based on SDOH data for recipients who are eligible for another exemption, for example, homelessness, waiver look-alikes or  those with serious and persistent mental illness, who do not receive SSI, would still be exempt from MMC.      
        
         c.  Medicaid’s enrollment broker and local social services districts must have clear, accurate and up-to-date information about provider networks and provider ability to take new patients including PCPs,  specialists, and clinical providers, not just individual HIV/AIDS specialists.

         d.  As required under New York State’s Partnership Plan, individualized and specialized enrollment/exemption assistance program for new enrollees should be implemented as an accommodation under Title I of the ADA.  This should be an extension of the basic assistance model provided by Medicaid’s enrollment broker.

5.  Post- Enrollment & Exemption Process:

         a. "Intelligent-assignment" instead of auto-enrollment is a fix for the worst aspects of problems with transitional care for disabled beneficiaries, including continuity of care issues.

         b.  Additional time and assistance for beneficiaries to choose a plan prior to auto-assignment and eliminating the 9 month “lock-in” period would alleviate transition and continuity of care problems and other barriers to accessing care. 

         c. Timely completion and transmission of health risk screening forms to health plans and case managers would also alleviate continuity of care issues.

         d. Plan should be sanctioned for failure to comply with the transitional care requirements of  the Public Health Law.

6. Case management/ Care Coordination Services: 

Case management  and care coordination services must be defined and structured so that enrollees receive assistance with plan navigation and access to plan services and information about in–plan benefits and those which are carved-out of the managed care benefit package.