Orthodontic Services Now Included in the
Medicaid Managed Care Benefit
As of October 1, 2012, HIP began covering braces for Medicaid members up to age 21 who exhibit a severe physically handicapping malocclusion and/or a qualifying congenital defect. HIP only covers cases reviewed and approved after October 1, 2012; Medicaid fee for service will continue to cover the treatment of children receiving orthodontic care whose treatment was started or approved prior to October 1, 2012, until their treatment is completed.
HIP members must receive an orthodontic referral from their assigned primary care dentist in order to access orthodontic services. The orthodontist will conduct an evaluation and submit the results to Healthplex, HIP's dental vendor, for review. Healthplex will apply the New York State orthodontic guidelines to determine if the case meets the criteria for orthodontic coverage. If treatment is approved, the same orthodontist who performed the evaluation will provide the treatment. There is no cost to the member if treatment is approved.
Consumer Direct Personal Assistance Program (CDPAP)
As of November 1, 2012, Medicaid managed care plans cover CDPAP services. CDPAP is a Medicaid program that provides services to chronically ill or physically disabled individuals who have a medical need for help with activities of daily living (ADLs) or skilled nursing services. Services can include any of the services provided by a personal care aide (home attendant), home health aide or nurse, and patients can choose their own caregivers.
CDPAP is only available for Medicaid members authorized for Personal Care Services (PCS).
When a doctor orders PCS for an eligible member, EmblemHealth sends a nurse to conduct an in-home health assessment to determine the level and amount of PCS needed and a social assessment to determine the members living conditions and available family support. The nurse will also explain CDPAP and, if the member is interested, will determine if he/she is eligible for the program.
The member or the person acting on the member's behalf (such as the parent of a disabled or chronically ill child) assumes full responsibility for hiring, training, supervising and, if necessary, terminating the employment of persons providing the services.
Medicaid Transportation Benefits Changing
The transportation benefit has changed for both Medicaid managed care and Family Health Plus (FHPlus) members enrolled in New York City since January 1, 2013:
Medicaid: Emergency and nonemergency medical transportation will be covered by regular Medicaid.
Family Health Plus: Nonemergency medical transportation will be covered by regular Medicaid.
This change in the Medicaid and FHPlus benefit affects UFT FHPlus members as well.
Nonemergency medical transportation includes: personal vehicles, buses, taxis, ambulettes and public transportation.
Obtaining nonemergency transportation after January 1, 2013
When members in New York City need nonemergency transportation on or after January 1, 2013, either your staff or the members themselves must call LogistiCare at 1-877-564-5922 for additional information or to schedule a trip. Deaf or hearing impaired members may use 1-866-288-3133 (TTY) to reserve these services. Members can also request nonemergency transportation services online.
LogistiCare should be called at least three days before the appointment and given the appointment date and time, the pick-up and drop-off addresses and the doctor's name. For Medicaid members, the patientís Medicaid Client Identification Number (CIN) must also be provided. The CIN is the same number as the ID number on the front of HIP Medicaid member ID cards, minus the first alpha character and the -01 suffix.
Note: New York City Medicaid, FHPlus and UFT FHPlus members will continue to get emergency transportation as they do now ó by calling 911. EMS will then bill Medicaid FFS or SDOH as appropriate.