Participants are provided access to the following covered items and services:
- All items and services provided under New York State Plan services (including long-term services and supports [LTSS]), excluding ICF/MR services and those services otherwise excluded or limited in the three-way contract
- All home and community-based waiver services
- All items and services provided under Medicare Part A
- All items and services provided under Medicare Part B
- All items and services provided under Medicare Part D. The integrated formulary must include any Medicaid-covered prescription drugs and certain nonprescription drugs that are excluded by Medicare Part D. The Medicaid-covered prescription and certain nonprescription drugs required for inclusion in the integrated formulary are those listed in the Medicaid State Plan. In all respects, unless stated otherwise in the MOU or the Contract, Part D requirements will continue to apply.
Glossary terms found on this page:
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. Also called a drug formulary.
An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.
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 nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
This part of Medicare provides benefits for hospitalization, extended care and nursing home care to Medicare beneficiaries with no premium payment for qualified individuals.
This part of Medicare provides medical surgical benefits for Medicare beneficiaries for a modest premium.
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 written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.
Drugs and medications that are required by law to be dispensed by written prescriptions from a licensed physician.