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  • 2019 Provider Networks and Member Benefit Plans > Medicaid State Plan and Demonstration Benefits for all Medicaid Managed Care Populations under 21 Included in the Children’s System Transformation

    Medicaid State Plan and Demonstration Benefits for all Medicaid Managed Care

    Services Current Delivery System MMCO Benefit Package
    Assertive Community Treatment (minimum age is 18 for medical necessity for this adult-oriented service) FFS 10/1/2019
    CFCO State Plan Services for children meeting eligibility criteria8 FFS 7/1/2019
    Children’s Crisis Intervention FFS/1915(c) Children’s Waiver service 1/1/2020
    Children’s Day Treatment FFS TBD
    Comprehensive psychiatric emergency program (CPEP) including Extended Observation Bed Current MMC Benefit for individuals age 21 and over 10/1/2019
    Continuing day treatment (minimum age is 18 for medical necessity for this adult-oriented service) FFS 10/1/2019
    CPST9 N/A (new SPA service) 1/1/2019
    Crisis Intervention Demonstration Service MMC Demonstration Benefit for all ages 1/1/2020
    Family Peer Support Services FFS/1915(c) Children’s waiver service 7/1/2019
    Health Home Care Management FFS 1/1/2019
    Inpatient psychiatric services Current Medicaid Managed Care Benefit Current Benefit
    Intensive Psychiatric Rehabilitation Treatment (IPRT) FFS 7/1/2018
    Licensed Behavioral Health Practitioner (NP-LBHP) Service MMC Demonstration Benefit for all ages Combined with OLP for 1/1/2019
    Licensed outpatient clinic services Current MMC Benefit Current Benefit
    Medically Managed detoxification (hospital based) Current Medicaid Managed Care Benefit Current Benefit
    Medically supervised inpatient detoxification Current Medicaid Managed Care Benefit Current Benefit
    Medically supervised outpatient withdrawal Current Medicaid Managed Care Benefit Current Benefit
    OASAS Inpatient Rehabilitation Services Current Medicaid Managed Care Benefit Current Benefit
    OASAS opioid treatment program (OTP) services FFS 10/1/2019
    OASAS Outpatient Rehabilitation Services FFS 10/1/2019
    OASAS Outpatient Services FFS 10/1/2019
    OMH State Operated Inpatient FFS TBD
    Other Licensed Practitioner (OLP) N/A (New SPA service) 1/1/2019
    Partial hospitalization FFS 10/1/2019
    Personalized Recovery Oriented Services (minimum age is 18 for medical necessity for this adult-oriented service) FFS 10/1/2019
    Psychosocial Rehabilitation (PSR) N/A (New SPA service) 1/1/2019
    Rehabilitation Services for residents of community residences FFS TBD
    Residential Addiction services MMC Demonstration Benefit for all ages 10/1/2019
    Residential Rehabilitation Services for Youth (RRSY) FFS TBD
    Residential Supports and Services (VFCA) (New Early and Periodic Screening, Diagnostic and Treatment [EPSDT] Prevention effect 10/1/2019) OCFS Foster Care 10/1/2019
    Residential Treatment Facility (RTF) FFS TBD
    Teaching Family Home FFS TBD
    Youth Peer Support and Training FFS/1915(c) Children’s Waiver service 1/1/2020

    8 Beginning 7/1/18, eligibility for CFCO benefits will become available to children who are eligible for Medicaid solely because of receipt of HCBS (i.e., Family of One children who meet institutional admission criteria and receive HCBS). These children are not eligible for CFCO under the State Plan but will be eligible for identical benefits under the 1115 Demonstration Waiver Amendment.

    9 NYS is exploring the use of EBPs. Pending CMS approval, these services will be billed through CPST and/or OLP, depending upon provider qualifications. Additional guidance will be issued regarding provider designation as well as the rate structure.

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    Glossary terms found on this page:

    Formal acceptance as an inpatient by an institution, hospital or health care facility.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    The government agency responsible for administering the Medicare and Medicaid programs.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.


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