A type of private health insurance product that typically has the following features:
- Capitation - the plan is paid a fixed amount per member per month by the payor (e.g., employer, union, Medicare, Medicaid) to provide a defined package of covered services. The plan's reimbursement does not vary based upon the amount or cost of medical care provided.
- Network - generally members of a managed care plan can only receive coverage for services provided by medical providers who have agreed in advance to participate in the plan's provider network, and thereby receive a contracted rate of payment.
- Utilization Management - the plan may impose restrictions on coverage of certain procedures, such as requiring the physician to obtain permission from the plan before performing them, or limiting the number of pills that can be prescribed. Some plans require members to have a primary care physician (PCP), and require the PCP to give referrals to any specialists before their services will be covered. Occasionally, managed care plans go further and proactively coordinate care among the member's providers.
Medicaid Advantage Plus - This is a type of managed care plan that includes virtually all services covered under Medicare and Medicaid. It is like a Medicare Advantage plan merged with a Medicaid managed care plan and an MLTC plan. It covers everything included in Medicaid Advantage, plus all MLTC services. This is one option for dual eligibles who are in need of LTC services and thereby required to enroll in MLTC (the other two are partial-cap MLTC and PACE). Otherwise, it is voluntary.
The acronym MAP is also used to refer to the Medical Assistance Program in New York (in other words, Medicaid).
Medicaid Buy-In for Working People with Disabilities
- A special Medicaid benefit that has a much higher income limit for people with disabilities who are working. See DOH MBI-WPD website.
Medicaid is the public health insurance program for people of limited means. It is jointly funded by the Federal, state, and local governments. However, each state has its own Medicaid program, which completely different rules regarding eligibility and what services are covered. You should assume that any information provided on this website only applies to the New York State Medicaid program (also known as "Medical Assistance").
A type of private managed care plan that is a combination of a Medicare Advantage plan and a Medicaid managed care plan. These plans cover all services under Medicare Parts A, B, & D, as well as almost all services covered under Fee-For-Service Medicaid in New York, with the exception of personal care, CDPAP, mental health, and adult day health care. This type of plan is always optional. It may make sense for dual eligibles who do not require long-term care services.
A model of care that gives each patient a more personal and continuous relationship with their physician(s). This can include round the clock access to medical consultations, more comprehensive care coordination, and providing both care and health education in a way that respects the patient’s beliefs and cultural background.
A federal category of Medicaid eligibility for people who are unable to afford their medical bills but have income and resource levels too high for traditional Medicaid. They may "spend down" their excess income and resources on medical bills to qualify for Medicaid. They must not be currently receiving any public cash assistance benefits, such as SSI or public assistance. Only certain "categories" of individuals are medically needy: DAB category (Disabled/Aged 65+/ Blind), and AFDC category (children under age 21, their parents or other relatives who live with them, and pregnant women).
A voluntary, optional program where Medicare beneficiaries may choose to enroll in a private managed care plan to receive their Medicare health insurance. These plans must cover all services provided under Medicare Parts A and B (and often D), except for hospice. Although they must cover the same services to roughly the same extent, there is considerable variation among plans in out-of-pocket costs, and unlike Original Medicare, members are generally limited to providers in the plan's network and subject to utilization management. Medicare Advantage plans may cover a few extra services not otherwise covered by Medicare (e.g., limited dental, limited vision, gym membership), and they may be a good option for beneficiaries who cannot afford the cost of supplemental Medigap policies, yet whose income is too high for Medicaid (which itself acts as a supplement to Medicare). To compare Medicare Advantage plans, see http://medicare.gov/find-a-plan
Medical Insurance and Community Services Administration - A division of New York City's Human Resources Administration that includes Adult Protective Services, the HIV/AIDS Services Administration, the Medical Assistance Program, and the Home Care Services Program. This is the agency that administers the Medicaid, Family Health Plus, and Child Health Plus programs in New York City.
Managed Long-Term Care
- in the general sense, refers to any type of private managed care organization in New York State whose benefit package includes Medicaid long-term care services (such as home care, adult day care, and nursing home). Currently, this general category includes Partially-Capitated MLTC plans as well as fully-capitated ones such as MAP and PACE. The term MLTC is more often used specifically to refer to the partially-capitated type of plan. These plans do not include any Medicare-covered services, nor do they include all services covered under Medicaid. Members of these plans must use them to access all types of home care, nursing home care, adult day care, medical transportation, podiatry, audiology, optometry, and dentistry. All other services are covered either by Medicare or Fee-For-Service Medicaid. Since 2012, it has been mandatory for dual eligibles needing Community-Based Long-Term Care services to enroll in MLTC, MAP or PACE plans in order to receive them. See http://www.wnylc.com/health/entry/114/