NY Manual
SHP Manual

New York Provider Manual
4.2 Marketing, Advertising, Outreach and Enrollment | 4.4 Eligibility Verification

4.3 PHSP Enrollment and Disenrollment

Mandatory Medicaid Managed Care

Medicaid recipients will have 30 days from notification that they must select a managed care plan to enroll in the plan of their choice. Family members may be enrolled into different plans and are no longer required to have one plan per family. Medicaid eligibles who do not select a managed care plan within the allotted time period will be “auto-assigned” to a plan by Maximus, the enrollment broker charged with managing all mandatory Medicaid managed care enrollments and disenrollments.

Once enrolled in a managed care plan, members will have 90 days to change plans, regardless of whether the selection was through choice or auto-assignment. After this period expires, members will be “locked in” to the plan for a period of nine months following the effective date of enrollment. If a member loses and regains Medicaid eligibility within three months, he/she will be automatically re-enrolled with Healthfirst.

Healthfirst will assign a maximum of 1,500 members to a Physician and 1,000 members to a Nurse Practitioner based on a 40-hour FTE. Panel sizes will be prorated when providers carry less than 40 hours at a practice site.

Child Health Plus (CHPlus)

Members will enroll in Healthfirst through the application process outlined in Section 4.1. The advertising/outreach guidelines and enrollment process described above also applies to the CHPlus Program.

Member Enrollment Rosters

Members are enrolled monthly into the Healthfirst programs. Each month, Healthfirst will provide PCPs with an enrollment roster for each program that identifies new members in the provider’s panel as well as those members who have left the practice. Providers may use these rosters to verify eligibility, however, if a member is not listed on the roster and says that he/she belongs to the provider’s panel, the provider should verify eligibility by accessing the Member Eligibility section of our web site or by calling Member Services. Member Enrollment Rosters are available on our web site at www.healthfirst.org/providers.

Newborns

When a Healthfirst member is pregnant, the PCP should notify Member Services and Medical Management as soon as the pregnancy is confirmed. The mother’s name, member ID number, the choice of PCP for the infant and the anticipated date of delivery should be provided at this time. Hospitals must notify Medical Management of all deliveries within one (1) business day of the child’s birth. Hospitals must also provide Healthfirst with the newborn’s Client Identification Number (CIN).

All newborns of Medicaid-eligible mothers are automatically assigned to the mother’s managed care plan at birth. Healthfirst Providers are required to accept a mother’s Healthfirst enrollment as sufficient proof of the newborn’s enrollment in the mother’s plan. The mother does not have to produce a Medicaid or Healthfirst ID for the infant.

Early notification of the pregnancy enables Healthfirst staff to ensure that a PCP is selected for the infant before the actual delivery takes place and that the member is offered Care Management prenatally and post-partum. The only exceptions to this policy are newborns that meet the exclusion criteria listed in the Medicaid Managed Care Exclusions table (see Appendix III). These infants are excluded from enrollment in any Medicaid managed care plan.

PCP Selection

Healthfirst members select a PCP upon enrollment. If no PCP is indicated on the enrollment form, Healthfirst will assign a PCP and issue notice to the member. Healthfirst Member Services staff provides assistance with PCP selection and changes. PCP changes are effective immediately.

Involuntary Change of PCP (Requesting Member Transfer)

PCPs may wish to arrange the transfer of a member to another provider. The provider may request a transfer of a member when the following situations exist:

·     Member is persistently noncompliant with a therapeutic regime
·     Member is verbally abusive to provider or staff
·     Member makes medically inappropriate demands or unreasonably refuses the provider’s recommendations

Providers should initially speak with the member to try to resolve the issue(s). If that cannot be done or is not successful, the following steps should be followed:

·     The member must receive a letter informing him/her that the PCP cannot remain his/her provider and the reason for this change
·     The letter must indicate that the member will have thirty (30) days from receipt of the letter to select another PCP and must inform the member that he/she should contact Healthfirst Member Services for assistance, if necessary
·     The member must be informed that the PCP will provide any needed care, medical services and/or prescriptions during the 30 day period
·     The member must be informed that the PCP will provide the member’s medical records to the new PCP if requested
·     The letter to the member should be sent certified mail, return receipt requested in order to ensure that the member receives the letter
·     A copy of the letter must be placed in the member’s medical record
·     A copy of the letter must be sent to the Provider Services Department
·     The provider should contact Healthfirst Member Services, provide the member’s name and Healthfirst ID number and inform them that the member requires assistance in selecting a new PCP

All of the above situations should be clearly documented in the medical record. For more information, please call Member Services at 1-866-463-6743.

Continuity of Care for New Members

In some situations, members enrolling with Healthfirst may continue care with their existing healthcare provider for a 60-day transitional period when there is a life-threatening, degenerative or disabling disease or condition under treatment. New members in the second trimester of pregnancy at the effective date of enrollment will be allowed to continue with their existing provider through the post-partum care associated with the delivery. Services received during this period must be consistent with the scope of benefits available to Medicare or Medicaid recipients, or those covered under the CHPlus program.

Non-participating providers who care for Healthfirst members during a transition period must adhere to the Healthfirst quality assurance protocols, policies and procedures and must accept Healthfirst reimbursement rates. Further, the practitioner will provide Healthfirst and the member’s new Healthfirst provider with medical information relevant to the member’s care.

New members may have preexisting appointments arranged for specialty care that were scheduled before their Healthfirst membership became active and the appropriate Healthfirst referral generated. If a new Healthfirst member presents in your office under these circumstances and does not have a referral from their Healthfirst PCP, please call Medical Management for assistance.

Disenrollment

There are two (2) types of disenrollment processes: voluntary and involuntary. Members may elect to disenroll from Healthfirst or Healthfirst may disenroll members for a variety of reasons.

Voluntary Disenrollment

Medicaid members may disenroll or transfer from Healthfirst after the 90-day grace period or for a “good cause” reason during the nine-month lock-in period. To disenroll from a Healthfirst program, such as CHPlus, members may contact the Member Services Department. For the Medicaid managed care program, members should contact New York Medicaid CHOICE at 1-800-505-5678. New York Medicaid CHOICE now processes all plan disenrollments. Medicare members should contact Medicare at 1-800-633-4227 or TTY 1-877-486-2048 for the hearing and speech impaired. Please note that there are restrictions on when and how Medicare beneficiaries can disenroll from Medicare plans. PCPs will be notified of all member disenrollments affecting their panels through the monthly enrollment rosters.

Involuntary Disenrollment

Healthfirst will not, either verbally or in writing, or by any action or inaction, request or encourage a member to disenroll from a Healthfirst program. However, there may be circumstances that require Healthfirst to involuntarily disenroll a member. These are as follows:

·     The member moves out of the Healthfirst service area
·     The member loses Medicare or Medicaid eligibility or is no longer eligible for CHPlus coverage
·     A member supplies fraudulent information or makes misrepresentations on the enrollment application that materially affects his or her eligibility to enroll in Healthfirst
·     A member’s behavior is disruptive, unruly, abusive or uncooperative to the extent that the Healthfirst practitioner’s ability to provide services is impaired (except where such behavior is related to an underlying physical and/or mental condition such as Tourette’s Syndrome)
·     A member knowingly permits abuse or misuse of the Healthfirst membership card
·     A member who is enrolled in CHPlus, Increased Benefits Plan, Life Improvement Plan, Maximum Plan or a commercial plan that has premium obligations fails to pay premiums. Reasonable efforts will be made to secure receipt of delinquent premiums; however, Healthfirst reserves the right to disenroll members under these circumstances if acceptable mitigating circumstances are not demonstrated  

Commercial Plans Enrollment and Disenrollment 

Enrollment

Individuals and families can enroll in Healthfirst Leaf plans through the NY State of Health website or in HMO A-D plans directly through Healthfirst.  The following individuals are eligible to sign up for a Healthfirst Leaf Plan:

·     Are under 65, are uninsured, and can’t get health insurance through their job.
·     Don’t currently have health insurance.
·     Are underinsured.  People are considered underinsured if their insurance plan does not cover the Essential Health Benefits required by the ACA.
·     Live within the five boroughs of New York City or Nassau County.     

Members must pay their monthly premiums to maintain enrollment in the health plan.  Members who receive federal premium subsidies have a 90 day ‘grace period’ to pay their premium, and members who do not receive subsidies have a 30 day grace period to pay their premium in full, should they miss a payment.  Members may enroll in a health plan during Open Enrollment.  The open enrollment period for 2015 when members can choose and enroll in a plan is 11/15/2014 – 1/15/2015.   

Newborns

When a Healthfirst member is pregnant, the PCP should notify Member Services and Medical Management as soon as the pregnancy is confirmed. The mother’s name, member ID number, the choice of PCP for the infant and the anticipated date of delivery should be provided at this time. Hospitals must notify Medical Management of all deliveries within one (1) business day of the child’s birth. Hospitals must also provide Healthfirst with the newborn’s Client Identification Number (CIN). 

 

PCP Selection

Healthfirst members select a PCP upon enrollment. If no PCP is indicated on the enrollment form, Healthfirst will assign a PCP and issue notice to the member. Healthfirst Member Services staff provides assistance with PCP selection and changes. PCP changes are effective immediately. 
 

Voluntary Disenrollment

Healthfirst Leaf Plan members may disenroll or transfer from Healthfirst during the open enrollment period or after a qualifying event. A qualifying event is any event that results in a change of income or family size such as marriage, divorce, birth of a child, loss of job. To disenroll from a Healthfirst program, members may contact the NY State of Health website or the Member Services Department. 
 

Involuntary Disenrollment

Healthfirst will not, either verbally or in writing, or by any action or inaction, request or encourage a member to disenroll from a Healthfirst program. However, there may be circumstances that require Healthfirst to involuntarily disenroll a member. These are as follows: 
·     The member moves out of the Healthfirst service area
·     The member gains Medicaid eligibility
·     A member supplies fraudulent information or makes misrepresentations on the enrollment application that materially affects his or her eligibility to enroll in Healthfirst
·     A member’s behavior is disruptive, unruly, abusive or uncooperative to the extent that the Healthfirst practitioner’s ability to provide services is impaired (except where such behavior is related to an underlying physical and/or mental condition such as Tourette’s Syndrome)
·     A member knowingly permits abuse or misuse of the Healthfirst membership card
·     A member who is enrolled a commercial plan that has premium obligations fails to pay premiums. Reasonable efforts will be made to secure receipt of delinquent premiums; however, Healthfirst reserves the right to disenroll members under these circumstances if acceptable mitigating circumstances are not demonstrated