New York State Medicaid State Plan Services

1. New York State MedicaidState Plan Services Optional Services: • Optometrist services; • Psychologists services; • Private duty nursing; • Clinic services; • Dental services; • Physical, Occupational therapy; • Speech, hearing and language disorders; • Drugs - prescription and non-prescription; • Dentures; • Prosthetic and orthotic devices, including hearing aids and prescription shoes; • Eyeglasses; • Diagnostic, screening, preventive, rehabilitative services; • Intermediate Care Facilities for the mentally retarded • Inpatient psychiatric services for under age 21; • Nursing facility services for under age 21; • Transportation • Personal care services; • Case management services; • Hospice care services; • Respiratory care services; • TB-Related services; • Other medical or remedial care recognized under state law. Mandated Services: • Inpatient hospital services; • Outpatient hospital services; • Rural health clinic and Federally Qualified Health Center services; • Laboratory and X-ray services; • Nurse practitioners' services; • Nursing facility services; • Home health services; • Early and Periodic Screening, Diagnosis, and Treatment for individuals under age 21; • Family planning services and supplies; • Physicians' services and medical and surgical services of a dentist; • Nurse-Midwife services

2. Analysis of NYS Medicaid Claims for FFY 2004 – 06Total Costs per Service Type and Unduplicated Count of Recipients

3. Medicaid Funding of the Continuum In New York State, over 65% of persons with HIV disease are either on Medicaid or are Medicaid pending. A regulatory framework has been established through the Medicaid program and HIV-specific Medicaid rates that provide a substantial source of ongoing support for HIV services. AIDS Institute Medicaid Initiatives • 1986Designated AIDS Centers • 1988 AIDS Nursing Facilities • 1989 Pediatric Maternal AIDS Centers • 1989 AIDS Home Care Programs • 1990 Community Follow-Up Program • 1990 HIV Primary Care Medicaid Program • 1991 Enhanced Fees for Physicians Programs • 1993 AIDS Adult Day Health Care Programs • 2003 HIV Special Needs Plans

4. Medicaid ReformImpact on HIV/AIDS Services • Fee for Service • Managed Care

5. WHY? SNPs Permanent Exemptions Medicaid Managed Care HIV FFS Infrastructure

6. HIV SNPs 101 HIV SNPs are NYS-Certified MCOs, separately licensed pursuant to Article 44 of the NYS PHL Eligibility: • All Medicaid managed care eligible individuals with HIV infection and their related children up to the age of nineteen. • HIV SNP enrollment is a VOLUNTARY CHOICE. • A SNP enrollee may disenroll at ANY time. Special Features & Services: • HIV Specialist PCPs • Enhanced PCP to Enrollee Ratios • Treatment Adherence Services • HIV Prevention & Risk-Reduction Education • HIV Care & Benefits Coordination • Networks that include HIV program models of care • Access standards appropriate to the HIV population

7. Care and Benefits Coordinationin Special Needs Plans • SNPs are responsible for providing and coordinating the Medicaid benefit package services and coordinating Medicaid services that are carved-out of the benefit package (e.g., pharmacy, COBRA Case Management) as well as non-Medicaid supportive services (e.g., community based case management, housing assistance, etc.). • This coordination aspect was previously referred to as “SNP Case Management” and this caused some confusion. • The current SNP Model Contract more accurately describes the SNP’s responsibility as HIV SNP Care & Benefits Coordination Services.

8. Care and Benefits Coordinationin Special Needs Plans • The SNP must ensure its enrollees receive Case Management services, but the SNP (generally) does not directly provide the Case Management service. • Case Management is just one component of the SNP’s Care and Benefits Coordination Services which includes: • Medical care coordination services in consultation with the PCP • Assessment & service plan development that addresses medical psychosocial needs • Service utilization monitoring and care advocacy services

9. Clarifying SNP Responsibilities Related to Case Management • The SNP shall assess Enrollees within the first thirty days to determine the level and type(s) of case management required. • The SNP shall identify the case management provider and assign the Enrollee to the CM provider within 30 days. • The SNP shall enter into linkage agreements with COBRA providers (where available) to promote access for Enrollees determined to be in need of such services. • If an Enrollee of the SNP is participating in a COBRA program, the SNP must work collaboratively with the CMCM case manager to coordinate the provision of services covered by the SNP.

10. The New “Y”Mandatory Program Emerging Clinical Issues Fiscal Climate Consumers Providers Evaluation Voluntary Enrollment