NY Manual
SHP Manual

New York Provider Manual
3.8 Termination of Provider Agreements | 4.2 Marketing, Advertising, Outreach and Enrollment

4. Eligibility and Membe​rship

4.1 Introduc​tion

Healthfirst Medicaid Managed Care Plan 

Members who are eligible for New York State Medicaid programs including TANF, SNA, Medicaid and SSI, and immigrants who are qualified aliens or fall under one of the permanent residence under color of law (PRUCOL) classifications, are also eligible for Healthfirst Medicaid. Coverage is available in Bronx, Kings, New York, Richmond, Queens, Nassau, and Suffolk counties.

To be eligible for the Medicaid program, a potential member must meet criteria which include household income, residency, citizenship, and alien status requirements. 

Enrollment in a Medicaid Managed Care Plan is now mandatory for the Medicaid-eligible population living in New York City and in Nassau and Suffolk counties. Those individuals who do not voluntarily select a plan will be assigned to a participating managed care plan by the New York State enrollment broker, New York Medicaid CHOICE, which is responsible for managing the mandatory enrollment process. However, there are certain categories of Medicaid recipients who are either excluded from the Medicaid managed care program or are exempt from mandatory enrollment. If you are treating members who qualify for an exemption, you may be required to complete an exemption form. This form must be submitted to New York Medicaid CHOICE for State Department of Health approval of the exemption. Exempt individuals have the option of choosing to join a managed care plan. Please contact Healthfirst if you have questions regarding managed care exemptions. See Appendix III for a complete list of the Medicaid Managed Care excluded and exempt population groups. To obtain exemption forms, please call the New York Medicaid CHOICE helpline at 1-800-505-5678.

Individuals who have access to healthcare coverage through their own or a family member’s employment with the federal, state, or county government, a municipality or a school district are not eligible to enroll in the Medicaid managed care program. Coverage for individuals meeting such criteria will end upon their next annual renewal date occurring after the effective date of implementation.

Medicaid Rec​ertification 

Medicaid members must recertify their eligibility for the program on an annual basis. Members will receive notice to recertify from their local district of Social Services. Notification will be received via mail reminding a member to renew their coverage. A member will be able to send their renewal form through the mail or renew online (for NYC members only. 

Child Health Plus ​(CHP)

CHP provides reasonably priced or no-cost healthcare coverage for children under the age of 19 for families who do not qualify for Medicaid and for whom the price of commercial health insurance is prohibitive. Those who qualify for Medicaid must pursue an application to participate in that program initially or upon recertification. The children are eligible for CHP regardless of immigration status, even if undocumented. Their families must be income-eligible to qualify for coverage under the New York State-sponsored CHP initiative that provides varying levels of subsidization for the insurance premium, depending on the family’s income level. Coverage is available in Bronx, Kings, New York, Richmond, Queens, Nassau, and Suffolk counties.

The application for CHP requires supporting documentation for income, identity/date of birth, and residency (must reside in New York State). CHP members who are pregnant should be referred to Medicaid. They will remain in CHP until their Medicaid eligibility determination is made. Prospective members’ eligibility will be determined by the contractor upon receipt of the application and required supporting documentation. If all requirements are not met, there is potential for a prospect to become a member with the plan and receive 60 days of temporary coverage—this is referred to as presumptive eligibility.  

CHP Recertification 

CHP members must recertify their eligibility for the program annually. An abbreviated application form, called the CHP Renewal Form, must be completed with new supporting documentation. The form is sent to a CHP member 90 days prior to the member’s anniversary date. It must be completed and submitted no later than 30 days before the anniversary date to ensure continuation of benefits. If it is determined that a member is Medicaid eligible, the member’s eligibility will be electronically submitted to HRA (NYC). For LI, the CHP Renewal Form will be submitted to the local district Social Services. If additional documentation is needed to properly process the recertification, a member may receive 60 days of presumptive coverage.

Providers are asked to note on the monthly enrollment roster which children are scheduled for annual renewal of eligibility and to communicate the importance of recertification to their families. This will avoid any lapse in coverage.

It may take up to 60 days to obtain documentation and verify eligibility for CHP. Therefore, applications are processed and members are considered presumptively eligible for 60 days while all documents are reviewed. Members will select PCPs and may access services during this period; providers will be compensated for services rendered. If, at the end of the 60 days, it is determined that the member is not eligible, he/she will be disenrolled.​ 

Medicare

Our Medicare programs are offered by Managed Health, Inc./Healthfirst Medicare Plan. There are a variety of HMO products available to individual members who are eligible for Medicare Part A and B and who will continue to pay their Medicare Part B premium. Some plans have additional eligibility criteria. Coverage is available in Bronx, Kings, Nassau, New York, Queens, Richmond, and Westchester counties. Our 65+, IBP, and CBP plans are available in Bronx, Kings, New York, Queens, Richmond, and Nassau counties, and the LIP, CCP, and MAX plans are also available in Westchester county. Our JBP plan is available in New York, Kings, and Queens counties. Our CC plan is available in New York, Bronx, Kings, Queens, and Richmond counties.

Commercial/QHP 

Our commercial programs are called Healthfirst Healthy NY, Healthfirst Leaf Plans, Healthfirst HMO A-D plans, and Healthfirst small group plans. Members are covered through individual contracts. New York State's Healthy NY program no longer offers coverage for individuals and sole proprietors, as of December 31, 2013.  Healthfirst Leaf Plans, Healthfirst Leaf Premier Plans, and Healthfirst HMO A-D plans for individuals and families are available in Bronx, Kings, New York, Richmond, Queens, Suffolk, and Nassau Counties. Healthfirst Healthy NY for small group coverage is available in Bronx, Kings, New York, Richmond, Queens, Nassau, and Suffolk counties.    

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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