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Medicaid

CAGN23091114EN - Medicaid Plans (2024) - Product Knowledge

  1. Manage care plans pay health care providers directly, so enrollees do not pay out-of the pocket for covered services recieved from the plans network of doctors,

  3. "on exchange" Enrollees who applied for medicaid through the new york state of health are known as On- Exchange Members. The term comes from the marketplace, or exchange, that enables New York State residents to apply for health care benefits.

  4. "Off Exchange" Enrollees who did not apply through the new york state of health and recieved their medical benefits via the HRA or LDSS are known as Off Exchange Members

  5. Medicaid Categories= Public assistance, Medical Assistance, Suplemental Assistance, Temporary Assistance for Needy Families (TANF)

  6. Mandatory Enrollment= Enrollees who are eligible for Medicaid are required to select a Managed Care Organization (MCO). New York State requires enrollees to select an MCO within 60 days of their confirmed eligibiltiy. 7.Grace Period= 90 Days New members can try us for 90 days. During their first 90 days, members can choose to disenroll in Senior Health Partners and join another health plan any time. If the member does not disenroll in the first 90 days, they must stay in senior health partners for the following nine months, unless they demonstrate a good cause reason.

  7. What can an individual do during this Grace Period=

  8. 9 months 10.What can an individual do during the lock-in Period?= After the grace period ends, enrollees must stay with their selected plan for the following 9 months. This is called the lock in period. During the lock in period, enrollees can only make changes if they can demonstrate a good cause, or a legitimate reason tha prevents them from staying with their current plan.

  9. What type of enrolless are excluded from choosing a Manage care Organization (MCO)

  10. What type of enrolles are exempt from choosing a MAnage Care Organization (MCO)= Some enrollees are exempted from the MAndatory Enrollment to a MAnaged Care Organization, its grace period, or the lock-in period, Examples of exempt individuals include. . People in a long term alcohol or residential drug program . People who are in regular <edical and are being treated for a chronic medical condition for 6 months or longer by a medical specialist not credentialied by a Medicaid Manage Plan. . Foster care children living in New York.

  11. What is the service area for the Medicaid Manage Care plan?

  12. What are the eligibility requirements for the Medicaid Manage Care plan?= 65 or older or under 65 with certain disabilities Resides in Bronx. Kings, New York, Queens, Richmond, Nassau, Orange, Sullivan, Rockland, or in Westchester counties

  13. List a few of covered benefits under the Medicaid Manage Care plan.= Medical, Hospital, Dental, Vision, Hearing, Pharmacy

16 How often does a member have to renew their Medicaid benefits?anually

  1. What happens if a member does not renew their Medicaid benefits? Members may loose their madecaid coverage.

============================================================================================ Madicaide The company code and harp is 01 format of ID Madicade/Senior Health Partner number always contain 2 letters 5 numbers and another letter at the end

Benefits= .Pre school and school services programs (corve out) . Early start/ intervention program . Non- Benefits free acces . HIV testing and counseling , Family planning . TB diagnois and treatment

Benefits non coverage .cosmteic surgery .Personal and comport items .some infertility treatments .services for which authorization is required and authorization was not obtained .out of network services

Benefits emergency & urgent care .United states .Commonwealth of puerto rico .U.S virgin islands .Guam .American Samoa .Northern Mariana Island

How can a Member Enroll On exchange = contact NYSOH at 1(855) 355 5777 from Monday to Friday 8AM to 8PM Saturday 9AM-1P Off Exchange = HRA/LDSS

Disenrollment, When/How can a member disenroll

On exchange Medicaid = 2-6 weeks Off exchange Medicaid = 2-6 weeks

Involuntary Disenrollment .Moves out of the Service area .Member is deceased or incarcerated .Becomes a permanent resident of a nursing home .Failure to recertify

Disenrollment: Deceased

on exchange . If you recieve a phone call from a family member or friend stating the member is deceased, please advise then to notify NYSOH/ . If the family member or friend refuses to contact NYSOH/HRA/LDSS, request that they mail or fax off exchange = HRA/LDSS

Disenrollment: Incarceration

on exchange . If you recieve a phone call from a family member or friend stating the member is incacerated, plaese advise them to notify NYSOH/ . If the family member or friend refuses, escalate to enrollment and billing department. off Exchange =HRA/LDSS

Service Agent Responsibiliteis . Behavior Health Providers/Specialist . Demographic changes . INN/OON Provider lookup . Eligibility/Benefit question and inquiries . Claims/Billing issues . All other complaints or request for appeals . SHP Healthfirst ID card request

Renewals and Disenrollment

Medicaid Renewal		Renewal Assistance		Disenrollment		How to
				. Healthfirst						. Written Letter
Annually			. HRA				Anytime			. HF SA or CM
				. LDSS							. NYMC

Member ID Number Senior Health Partner member number will always contain 2 letters, 5 numbers, and another letter. Ex. AB12345C

Marketplace plan = always check Biztalk on Exchange/medicaid/child health plus/on exchange qualified plan

After you upadate the Medicare demograpic changes they need to contact the state entity to confirm the changes.

Medicare through MARX