New York
In New York:
- Most children and adults who qualify for Medicaid are enrolled into Medicaid managed care under two separate 1115 waiver programs: the New York Partnership Health Plan for individuals who belong to an income-eligible family, and a separate program for adults or children (age 0-64) who are receiving SSI payments or are otherwise disabled. Under these programs:
- Physical health services are delivered by either an managed care organization (MCO) or a primary care case management (PCCM) provider;
- Mental health and chemical dependence inpatient rehabilitation services are delivered through MCOs to all children enrolled in MCOs through the Partnership Health Plan. Historically, all SSI and SSI-related managed care enrollees have received mental health and chemical dependence inpatient services through fee-for-service, and outpatient substance abuse services provided by clinics certified by the Office of Alcohol and Substance Abuse Services have been carved out from managed care benefits under two 1115 waiver programs.
- Under the recommendations of a Medicaid Redesign Team (MRT), New York is moving to phase out the utilization of most fee-for-service Medicaid behavioral health services. In 2013, behavioral health organizations (BHOs) began risk-bearing Medicaid managed care for adults and children with serious mental illnesses or substance use disorders. New York State’s MRT goal is to have most children receive their behavioral health services through a managed care plan or BHO by April 2015.
- All MCO enrollees receive dental services from their MCO. Those not enrolled into an MCO receive these benefits on fee-for-service.
- There were a total of 4,925,236 beneficiaries enrolled in New York’s Medicaid program as of July 2011. Of these, 3,777,868 were enrolled in managed care; 3,725,644 were enrolled in a commercial or Medicaid-only MCO and 14,091 were enrolled in PCCM.
As of 2012, 2,280,280 individuals (aged 0-20) were eligible for New York’s Medicaid benefit for children and adolescents (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT) benefit, known in New York as the Child Teen Health Program (CTHP). According to CMS data from 2012, CTHP achieved a screening ratio of 92% and a participation ratio of 60%. 852,032 children received dental services, with 797,703 receiving preventive dental services.
Last updated December 2013.
| Medical Necessity |
New York state law provides a definition of medical necessity:
“Medical assistance” shall mean payment of part or all of the cost of medically necessary medical, dental and remedial care, services and supplies, as authorized in this title or the regulations of the department, which are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person’s capacity for normal activity, or threaten some significant handicap and which are furnished an eligible person in accordance with this title and the regulations of the department.
The state does not have distinct statutory definitions for children, oral health services, or behavioral health services.
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| Initiatives to Improve Access |
Behavioral Health
In October of 2011, New York expanded Medicaid reimbursement for telemedicine services to additional care settings, and incorporated tele-psychiatry into the model. The Office of Mental Health’s (OMH) Division of Child and Family Services has established a New York Consultation and Telepsychiatry (NYCaT) program to address child psychiatric consultation needs in areas of the state with workforce shortages. The program supports mental health treatments for children in mental health programs as well as in primary care practices. To improve access to behavioral health services, New York made a policy change with CMS approval in mid-2011 allowing Medicaid reimbursement for counseling services provided by social workers. Before that change, only Federally Qualified Health Centers had been able to seek reimbursement for those services when provided by social workers.
Managed Care Incentives
New York has incorporated managed care plan performance on well child measures into its auto-assignment algorithm; higher-performing MCOs are assigned a higher proportion of new enrollees who do not make a specific choice when they enroll.
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| Reporting & Data Collection |
Reporting on quality of services for children
Medicaid officials in New York rely on a combination of National Committee for Quality Assurance (NCQA) Health Effectiveness Data and Information Set (HEDIS) measures and additional measures developed by the state—together known in New York as the Quality Assurance Reporting Requirements (QARR)—to monitor the quality of care provided by Medicaid MCOs. Several child-specific HEDIS measures are included in required reporting under New York’s QARR, including measures for well-child visits in the first 15 months of life, well-child visits in the 3rd, 4th, 5th, and 6th year, and adolescent well-care visits. This data is used to issue MCO-specific performance reports. The MCOs submit person-specific data on an annual basis that the Medicaid agency can use to analyze the results by race and ethnicity, location, and Medicaid coverage group. The Medicaid agency offers a managed care reference guide on encounter data submissions to provide MCOs with additional information on the process.
Collecting data for the Form CMS-416
New York requires MCOs to submit encounter data on physical health, mental health, and (where applicable) oral health to the Medicaid agency. Data elements included in encounter data include procedure codes and are listed in the “MEDS II Data Element Dictionary.” Each month Medicaid-contracted MCOs submit electronic encounter data. This data, along with claims submitted through the fee-for-service Medicaid system, is used to populate the Form CMS-416. Claims data for dental services or services provided to children who are not enrolled in managed care is submitted to eMedNY, the Medicaid program’s claims processing system. Managed care encounter data is also used to calculate risk-adjusted capitation rates, giving managed care plans a financial incentive not to underreport data.
Oral Health
Medicaid uses fee-for-service claims data and encounter data from MCOs to determine the number of sealants placed.
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| Behavioral Health |
New York’s provider manual for the Child Teen Health Program was a joint Title V/Medicaid effort, and was revamped to ensure that it addressed child and adolescent emotional and behavioral health and incorporated evidence based practices.
New York Medicaid reimburses for Screening, Brief Intervention and Referral to Treatment (SBIRT) services for all Medicaid beneficiaries who are 10 years of age and older. These services are covered in hospital outpatient and emergency departments, free-standing diagnostic and treatment centers (including School-Based Health Centers), and office-based primary care practices.
New York has several home and community-based services waivers that target services to children with behavioral health conditions including:
In New York’s EPSDT/CTHP Provider Manual For Child Health Plus A (Medicaid), providers are referred to the Bright Futures in Practice: Mental Health Volume 2 Tool Kit for screening tools, including the Pediatric Symptom Checklist.
For more information about behavioral health services for children enrolled in Medicaid, see “Behavioral Health in the Medicaid Benefit for Children and Adolescents: New York.”
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| Support to Providers and Families |
Support to Families
New York’s Medicaid MCO contract requires MCOs to:
Managed care contracts require MCOs to provide member handbooks and other health education through methods such as distribution of Enrollee newsletters, health education classes, or individual counseling. MCOs also typically have member portals on their websites that contain information about benefits, such as an electronic version of a Medicaid Managed Care Member Handbook.
Support to Providers
Managed care contracts require MCOs to “Educate Participating Providers about the [Child/Teen Health] program and their responsibilities under it.” The Medical Director for the Department of Health’s Office of Health Insurance Plans meets with MCO medical directors on a quarterly basis and communicates any changes in contracts or benefits to the MCOs, who can then relay the information to the provider community.
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| Care Coordination |
Children as well as adults are being enrolled into two medical home initiatives in New York:
The state is pursuing Health Homes authorized to receive additional federal financial participation under Section 2703 of the Affordable Care Act. Children are eligible to receive health home services; however, the state is using a priority enrollment algorithm that prioritizes non-pediatric populations. The state has also considered developing a health home program specifically for children.
The state’s Coordinated Children’s Services Initiative is a multi-agency initiative that supports county-level provision of cross-systems services to children with serious emotional disturbance (SED) who are at risk of residential placement. At the state level, participating partners include the Department of Health (which houses the Medicaid agency) and the Office of Mental Health. Every county in New York has designated a Single Point of Access to link children to Office of Mental Health (OMH) resources.
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| Oral Health |
New York Medicaid’s dental delivery system relies on nearly 180 freestanding dental clinics throughout the state; over 90% of dentists in the state are practicing in private settings.
Dental services such as dental screenings and fluoride treatments are also provided to children through school-based health centers (SBHCs), including comprehensive SBHCs as well as Dental SBHCs dedicated specifically to providing dental services. Dental hygienists, dental assistants, and supervising dentists are all examples of staff that SBHCs are permitted to add to provide expanded services according to local need.
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For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
