Managed Care and Medicaid in New York - Essay Example

Managed Care and Medicaid in New York Medical care is an important aspect of life in every society. This is due to the fact that all individuals in the society need to be in a healthy state in order to proceed with developmental activities in the society. However, with the harsh economic times and a large number of people living below poverty level, most states and governments step in to assist with the provision of healthcare. This is through various schemes that are provided by employers, private companies or the government in some cases. This is done in a bid to ensure that almost all individuals in the country have access to proper medical care. The United States is one such country. Despite the fact that most insurance providers are employers, Medicare and Medicaid also provide insurance covers for individuals. Provision of medical care is one of the areas that governments try to get complete control over. In the United States, this responsibility is given to various counties. In cases where provision of health care insurance is provided by the employer, it is the employer that has complete responsibility of the rules that will prevail and the kind of cover that will be provided. This includes cases on whether the spouses are covered and to what percentage the cover will provide or if the cover will extend past retirement period or not. When the government provides insurance cover, it is always done to specific individuals of the society. This depends on whether they qualify for such provisions, most of the time, the governments covers the disabled, poor as well as the old. Medicaid is one of the state providers of insurance cover in New York. This paper will be a discussion of Medicaid in New York and how Managed Care Medicaid has take over and where it is headed. Medicaid is a health program in the United States. It was created as a function of the Social Security changes that were made in 1965 to ensure that the disadvantaged groups in the United States receive medical attention. This was as a result of the difficulties that were being encountered by some sections of the population while seeking medical care. The program was meant to cover for the medical needs of certain groups of people that are considered deserving. These are mostly people that have low incomes and few other means of survival. People with disabilities also benefit from this program. Medicaid is funded by the state together with the federal government (HANYS, 2012). Medicaid services are available in every state of the United States and they are among the leading health insurance providers. Each state is responsible for the administration of this program within its state; however, it is the federal government that monitors all the state programs. It also decides on issues to do with service delivery, quality, funding and eligibility standards. New York’s Medicaid program has always been on the forefront in the provision of medical care. Since its inception in 1966, the New York governor at that time Nelson Rockefeller required that New York City contribute 25 percent of the cost. The federal government would contribute 50% with the state providing 25% (Slavin, 2012). There was no any other state where the locals had to pay such high amounts for medical costs. However, for a period reaching the early years of the past decade, New York county contributions kept increasing. In the preceding years, the local contribution to Medicaid has reduced to a much smaller percentage, 3.5%, and an even further reduction to 3% (Slavin, 2012). Despite this reduction, some counties in New York were still struggling with Medicaid payments. For example, Essex County in New York currently spends 43% of its tax levy on Medicaid. This was a high tax levy considering the criteria that is used to qualify someone for Medicaid in New York (Slavin, 2012). One must be a resident of New York, a US national, citizen as well as a permanent resident or legal alien of the states and in need of health care insurance. For all the people that meet the above criteria, their financial capability should be classified as low or very low income. Pregnant persons, parents or relatives that have dependents under the age of 19 years also qualify for the program. In addition to this, people with disabilities and those that are above 65 years of age are also given a cover under the Medicaid program in New York. All these groups of people are considered needy, therefore the provision that they contributed towards Medicaid had to be reduced. There were situations when Medicaid required some co-payments, but considering the group of citizens that Medicaid covers, it would be hard for them to come up, with the additional cost. Despite these challenges that Medicare has been having, New York State has struggled to provide coverage to all individuals within the state that are eligible for Medicaid. Thus, New York has become an example in the whole United States in the effort to expand eligibility. In addition, the New York Medicaid program also strives to ensure that people who were covered by the program do not drop out of the system without proper reasons (HANYS, 2012). As a result of this, New York has a lower rate of uninsured citizens compared to other parts of the nation. With the Federal government struggling to expand coverage to those who do not have any form of insurance, New York was being instrumental in ensuring that this objective is met. The creation of Child and Family Health Plus programs under the New York’s Medicaid program was an indication of their commitment in ensuring that cover was extended to those who could otherwise not afford it (HANYS, 2012). The New York State Division of Budget shows that the utilization of Medicaid services will increase by 4.1 percent. This is an indication that there is the possibility of almost $400 million of expenditures that had not been anticipated (HANYS, 2012). This is attributed to the fact that New York enrolls a greater percentage of its population under Medicaid as compared to the whole nation. The cost of living, wage differences and the percentage of people with chronic diseases in the population contribute to the higher spending that is witnessed in New York compared to other states (HANYS, 2012). These problems and other difficulties that Medicaid was facing led to the formation of Medicaid Manage Care. The Medicaid Managed Care Plan offers many citizens an opportunity to get a health plan that is more favorable. The managed care plan looks into preventive health care and provides the people that are enrolled in it a medical home. This also covers their families and other dependents that are listed under the program. If one is eligible for Medicaid, they can join a managed care plan that suits their needs. Under the Managed Care Plan, one selects a regular doctor, who in this case is referred to as a primary care practitioner (NYS, 2012). This doctor becomes responsible for coordinating the health care needs of a particular individual that is ascribed to them. He will be responsible for making referrals to specialists and other health care providers and procedures when necessary. The whole plan always has a association of professionals and hospitals and when selecting the health care provider, one has to choose one among this network. There are different types of managed care programs for one to choose from. These serve residents from all age groups and from various income levels. Health care providers in this program are paid directly from the Managed Care system. Therefore, those that are enrolled under this program do not have to pay for services that they receive on account of Medicare Managed Care. The other option of submitting claim forms may not apply in this situation. In July 1997, the federal government gave New York State a waiver allowing the state to require all Medicaid beneficiaries to join a Medicaid Managed Care Plan, in order to continue receiving Medicaid benefits. Many Medicaid beneficiaries are enrolled in the Managed Care Program (NYS, 2012). There is mandated enrollment in the plan with those that are required to join being temporary assistance recipients, safety net recipients, Medicaid recipients without any money to spend and SSI recipients (disabled, blind and those above 65 years of age). Individuals that have an exemption can still join a plan but this is not mandatory for them. On the other hand, there are Medicaid recipients that are excluded from joining any Medicaid Managed Care Plan, for these individuals, they cannot join any plan even if they wanted to join one (NYS, 2012). In September 2010, the State Department of Health began expanding managed care enrollment in New York City to Medicaid beneficiaries with HIV/AIDS. Earlier, this group of persons had been exempted from the Managed Care Plan on the basis of their HIV infection. People that are covered under Medicaid and qualify for Managed Care Plans are informed of the requirement to join a Medicaid Managed Care Plan by mail immediately they join Medicaid (NYS, 2012). The mail contains the enrollment package that includes the New York Medicaid Choice Guide, a health plan list which includes participating hospitals, a consumer guide to Medicaid Managed Care in New York, a Mandatory notice letter and an enrollment form with a stamped return envelope. Once a potential Medicaid Managed Care Plan beneficiary responds, they are taken through a health risk assessment. The Health Risk Assessment includes basic health information on the potential beneficiary. It helps the health plan in determining the programs under which they will be enrolled based on the health needs that they have. Enrollees must use providers in the health plan network that they join except in limited circumstances such as when they need family planning services or visits to the emergency room at non-participating hospitals (NYS, 2012). Despite the fact that enrollees receive a plan identification card from the health plan, they retain their Medicaid cards so that they can access services that are covered under Medicaid but are not provided by the Medicaid Managed Care Plan that they join. These are mainly family planning and reproductive health services (NYS, 2012). The Medicaid Managed Care Plan is better than Medicaid due to the fact that beneficiaries in this health plan belong to a ‘medical home’, each enrollee has his or her own doctor who knows their medical history (NYS, 2012). This makes it easier to assist the patient. Health plans also focus on preventive measures, thus they provide education to the enrollees and the community that they serve on several health concerns such as asthma, smoking, nutrition, STDs and HIV/AIDS education as well as family planning. Injury and violence prevention, domestic violence and mental health services are among the educational services that they provide. These kinds of services are not provided by Medicaid (NYS, 2012). In order to ensure that they operate at their optimum possible level, Medicaid Managed Care Plan has several plans for the future. First, it plans to have population expansion. This is to ensure that most groups that are currently exempted from enrolment get a cover. Managed Care plans to do this so that a larger proportion of the population can get access to medical care. For example, individuals receiving services through the Nursing Home Transition and Diversion Waiver would receive cover after Medicaid Managed Care Program (Jung, 2011). Non-institutionalized foster care children would also be eligible for care under the Medicaid Managed Care Program through the institutions that they are under. These are some of the groups that were exempted from Medicaid Managed Care Plan but they are going to be incorporated into the scheme (Jung, 2011). There have also been problems with low literacy and language barriers in the provision of services under the Medicaid Managed Care Program. This has affected the enrollment and service navigation. In response to this problem, the Medicaid Managed Care Program has formed a Managed Care Workgroup to focus on this issue. With this plan in place, it is possible that such problems will soon be eliminated in the Medicaid Managed Care Plan (Jung, 2011). In conclusion, Medicaid is one of the leading health care providers in the United States, in New York, it is the body that supports a great number of inhabitants with the health care needs that they have. However, due to some of the setbacks that the program was having and with the need to have a more effective system, Medicaid Managed Care Program took over most of the services that were earlier being provided by Medicaid. This program has been instrumental in integrating more specialists and services in the process of taking care of the needs of those people that are enrolled in it and has received quite a great deal of success. However, more amendments are being done on the system to ensure that it accommodates more people and that more and better services are provided. References Healthcare Association of New York State, (HANYS). (2009). A Closer Look at New York State’s Medicaid Program: Patients, Providers and Policy Choices. Retrieved on 10th April from http://www.hanys.org/finance/reports/2009-02-25_medicaid_wp.pdf Jung, T. (2011). New York Dramatically Expands Mandatory Managed Care for Medicaid Beneficiaries. Empire Justice Center. NYC Health (2012). Medicaid Managed Care in New York City. Retrieved on 10th April 2012 from http://www.nyc.gov/html/doh/html/hca/hca1.shtml Slavin, R. (2012). New York State Plans to Lighten Local Medicaid Burden. The Daily Newspaper of Public Finance Read More