NY leaves HMO doors wide open to special needs Medicaid clients
NY HMO Medicaid
January 31, 1998
Largely because of intensive lobbying by advocacy groups, populations ranging from mentally retarded residents of intermediate care facilities to severely disabled children can sign up with HMOs participating in New York’s Medicaid managed care program. While there is an increasing trend around the nation to allow Medicaid recipients who are exempted from mandatory managed care to voluntarily enroll in managed care plans, New York seems to be leaving the door wide open.
New York has a fairly lengthy list of conditions that allow for Medicaid recipients to be exempted from mandatory enrollment into Medicaid managed care. But that same list also is an invitation for them to join voluntarily.
"Look at the wording of our exemptions," said New York Health Department spokesman Robert Hinckley. "You’ll see that for many of them, it said that they can’t be required to sign up, but they’re welcome to join voluntarily."
"The rationale is to give people a choice," added Barbara Frankel, of the department’s Office of Managed Care.
"A lot of times what’s included in their exemptions actually sounds like they’re making the program more open," said Neva Kaye, director of the Medicaid Managed Care Resource Center at the National Academy for State Health Policy. Ms. Kaye headed a survey prepared by the Academy in June 1996 which looked at states’ enrollment policies for mandatory managed care. Based on that survey (which the center plans to do again this spring) and her knowledge of what policies states have been following since then, Ms. Kaye noted that New York’s list of exemptions "is reasonably in line with what other states are doing."
But the breadth of recipients who can join voluntarily in New York is unusual, she added. Among those groups who can voluntarily enroll is the SSI population. "Some states simply don’t have a program to enroll SSI recipients at all," she said.
Also exempted from mandatory participation in New York’s program but allowed to voluntarily enroll are residents of alcohol and drug treatment facilities, developmentally disabled individuals receiving services at home through a Medicaid Home and Community-Based Services Waiver program and the homeless.
New York’s list of exemption definitions even includes those "individuals with characteristics and needs similar to" a number of the exempted groups.
"The expansion to the look-alike populations is new," she said. "Although it depends on how you look at it. Other states have a blanket sort of, you can do it if you want to’ provision.... It depends on how well-defined that language is and how it’s applied."
According to Susan Dooha, of the Gay Menís Health Crisis in New York City, "advocacy groups did say people should have a choice, including people who have been avoided by HMOs in the past," Ms. Dooha was a member of the managed care task force put together by health care consumer groups to work with the Health Care Financing Administration and the state on the waiver.
"We don’t believe any health care financing institution should be able to discriminate against medically-underserved communities that can’t get the health care they need and are willing to try to get it in an HMO," Ms. Dooha said. "The HMOs should be held accountable for serving them."
What’s happening in New York, she added, is an acceleration of a national trend.
"The door is being opened, not only in New York but increasingly around the country. In the past, these aren’t people who could get in the door—or when they got in, they had a lousy experience."
Ms. Dooha said the issue of whether managed care providers can guarantee recipients with special needs the quality of health care they need is what consumer groups are most concerned about.
"We want the benefits of managed care that are available to everybody else to be available to people with special needs. But we also want to make sure that once you get inside this new medical home, it really is designed with your needs in mind."
NY leaves HMO doors wide open to special needs Medicaid clients
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