NY Medicaid woes
January 19, 2016 10:59 PM   Subscribe

When I turned 26 a few weeks ago, I was summarily dropped from the health insurance my mother gets through her job ( I was eligible to stay until 26 b/c of a disability). Now, I'm facing a nightmarish bureaucracy trying to get enrolled in managed care before the 31st. Help me shovel some snowflakes out of my way so I can actually do this right.

YANM enrollment counselor or insurance professional. Got it. Still, I've been having so much trouble getting myself health insurance that I figure the hivemind could help.

See, right now I have regular, straight Medicaid. It's okay, but I feel like managed care is better because it gives me access to more providers. Or, that's what I thought. I'm not sure what to make of anything at this point.
Some general questons:
- What are the functional, real-life differences between straight and managed care plans?
- Which MCP, in your experience, is best? Some of the things I need to be covered include:
* Bariatric ( lap-band) surgery at some point within the next six months
* A GOOD psychologist/psychiatrist
* DME- crutches and power wheelchairs and repairs to said wheelchair
* Good physical therapy visit policies ( in terms of frequency per year, or how easy it is to get more visits)
* Some major dental care***
* Mostly tier 1 drugs
Obviously also interested in hearing which plan you feel has the best doctors in general, and which to avoid.

***My main bureaucratic issue has been trying to get Medicaid to remove the third party codes from my file so I can enroll. I've managed to get all my old insurances removed ( finally, after WAY too many f*cking phone calls, heh) but they're telling me the dental has to go too. Is this true? I like my current dental plan and I'm not sure I want to give it up. What are my options here?

Finally, is there anything I can do to extend my enrollment period, given the situation I'm in?

I know this is a lot to chew on. I'm looking for both anecdata and professional advice, if you're in a position to give it. Thanks all!
posted by marsbar77 to Health & Fitness (10 answers total)
Forgot to mention that my dental plan, which I don't know how I still have, is an Aetna PPO under my mom.
posted by marsbar77 at 11:00 PM on January 19, 2016

Also, is there something I'm missing with Obamacare plans? They were touted as being affordable, but I can't find anything decent for under 500 a month. I'd love to get off Medicaid altogether if I had the choice to go private.
posted by marsbar77 at 11:03 PM on January 19, 2016

To answer your first question, regular Medicaid (aka fee-for-service) lets you go to any doctor who takes Medicaid. With managed care Medicaid, you have to see the doctors within that plan's network. You'll choose a primary care provider, and that provider will be your starting point if you need referrals to other services.

One of the benefits of managed care is care management. So if you have a tricky/intensive medical condition in the short or long term, you'll have access to a care manager/case manager/care coordinator type person who will coordinate your care and services for you.

You mentioned New York in your tags, so here's a link to New York Medicaid Choice, where there's a number you can call to ask questions about different plans. (There are several in NY.) In general, the state requires the various participating plans to provide similar levels of covered services, but each plan will have different network providers and potentially different value-adds (extra bells & whistles). If you have a doctor you love, you would want to make sure that doctor would be in your selected plan's network.
posted by mochapickle at 11:59 PM on January 19, 2016 [1 favorite]

Thanks, mochapickle.
I haven't had the best of luck with Medicaid Choice. They really only seem good for very superficial questions. But maybe things are different once I'm eligible to enroll.

I don't understand the network thing though.... Is straight Medicaid not its own network? Am I wrong in thinking that, as of right now, I can only see people who take non-managed Medicaid specifically?
Gah, okay. No more threadsitting.
posted by marsbar77 at 12:31 AM on January 20, 2016

Is straight Medicaid not its own network? Am I wrong in thinking that, as of right now, I can only see people who take non-managed Medicaid specifically?

Not really. A provider doing straight fee-for-service Medicaid may also be in one or even several managed care plan networks. Just depends on the provider.

Also, was just thinking about the bariatric surgery issue. If I recall correctly, availability for that procedure depends on the state, and when it is available, each state may have its own requirements about prereqs for getting that done: For example, the patient may have to complete a lengthy, physician-led weight loss program for a certain period of time before advancing to surgery.

Dental: Again, my memory's a little fuzzy on this one, but I think New York Medicaid doesn't carve in (aka include) dental. So that's probably why you're hitting a wall there. Here is a link re: the current dental benefit, and there's really not much there. FWIW, not a lot of states are carving in dental so most people are in the same boat.

Behavioral health: New York did carve in behavioral health into managed care starting in 2015/2016, so that makes it easier to access under managed care. For severe and intensive behavioral health issues (like substance abuse, severe mental health issues) there's New York HARP.

I haven't really followed managed care in NY for a couple of years now, so hoping people closer to the market out there can chime in and correct me where needed.
posted by mochapickle at 1:26 AM on January 20, 2016

Also, is there something I'm missing with Obamacare plans? They were touted as being affordable, but I can't find anything decent for under 500 a month.

Affordability isn't really the central thing—it's more that, for example, you can't be denied coverage for preexisting conditions and the like anymore. But surely if you're on Medicaid you'd also qualify for an ACA subsidy?
posted by listen, lady at 4:40 AM on January 20, 2016

Oh, hai, subject I know way too much about. My experiences are in Texas only, so some things may be a bit different in New York, but most should be generalizable.

1) I'm on a managed care Medicaid plan and if I could switch to straight Medicaid I'd do it in a heartbeat. It's mandatory for adults with disabilities in my area to be on a managed care plan. They offer "value added services", which for me have not proved to be much of a value-add. For example, they will give you a gift certificate towards new gym clothes if you join Weight Watchers, or something. It's nothing compared to the freedom to use Medicaid at my actual primary care doctor, because he doesn't accept the HMO. I have found HMO panels to be far more limited, and you always always have to get a referral from your primary (no self-referring to your specialist, even if that's who you see far more often). Mental health panels are woefully limited.

2) There is a program in Texas, and may be one like it in New York, where you can apply to have Medicaid pay for your premiums to a regular insurance plan. They evaluate the costs and your eligibility, and let you know -- in my case, if I were eligible, it would have paid for the premiums plus all of my out of pocket, and it would have saved the state thousands of dollars a year. But I couldn't because the HMO was mandatory.

3) I looked up premiums in Manhattan for a man your age and got $325 for a plan including dental. Granted I have no idea how good it is, so you may have to go higher to get the benefits you need, but the $500 seems awfully high as a bare minimum.

4) If you're on Medicaid you can't get an ACA subsidy because you fall below the floor for the income requirement. You're considered to already have adequate coverage, so no help buying a better plan.

5) On the up side, if you have private insurance and Medicaid, with coordination of benefits Medicaid should pick up all of your out-of-pocket stuff that's in network. That is, I had a hospitalization last week that my private insurance was the primary on (Medicaid is almost always the payer of last resort). My OOP max on that insurance is $1500 for the year. The coinsurance portion of my hospital stay will take that up and more, but I'm not on the hook for it -- because it was at a facility that also takes my Medicaid, they'll pick up the OOP expenses and it's $0 to me. Plus since I've met my OOP max, all remaining care on my primary insurance is completely covered, even visits to doctors that don't take Medicaid.

6) Practical steps: Identify the doctors you would like to be seeing. If you want to switch primaries, if there are particular specialists you want, etc. Find out what insurance they take and base your decision on that. Check the member manual for the HMO programs you're looking at and make sure that they offer the benefits you need. Compare to straight Medicaid. If you do go with an Obamacare plan because you want to see doctors that aren't on Medicaid, do the math on premiums + OOP max for the year to see which plan is actually most cost-effective for you. I went with a higher tier plan because, knowing I was going to blast through my OOP, I knew I wasn't going to save any money going with a high deductible plan. That would actually have been okay this year, since I had the hospitalization early that Medicaid's picking up the OOP for, but if I'd had a bunch of non-Medicaid doctor visits or whatever beforehand I'd have been on the hook.

7) If you can't manage to get it worked out by the 31st, a qualifying life event is your best bet for switching after the fact. Moving, getting married/divorced, etc.

8) Know that you're not alone. The amount of times I've cried over trying to get insurance straightened out/find a decent mental health professional who takes my insurance/get prescriptions covered, even with Obamacare and Medicaid and a lot of resources at my disposal, is ridiculously high. It's all a mess. I love Obamacare and bless it daily, but there's still an incredible amount of bureaucracy and difficulty navigating the entire system. I'm very very jealous of countries with single-payer; it just seems so much more civilized. And not crazy-making.

Feel free to Memail me if you'd like some help working through the options. Again, I don't have any NY-specific knowledge, so I can't speak to particular plans or doctors, but I'm pretty good at figuring out the angles on the system.
Oh, yeah, the other thing -- if you don't need/qualify for Obamacare subsidies, you don't have to go through the exchange. You can buy straight from an insurance company, so if for example you need more dental coverage you could go to the company's website and buy from them. I got a $40/mo plan that doesn't cover a crazy amount, but should prove worth it because I need some fillings done and I'll get my cleanings for free.
Good luck, and be careful out there.
posted by katemonster at 6:03 AM on January 20, 2016 [1 favorite]

Oh, yeah: it appears in NY you MUST stay on straight Medicaid if you have other full-benefit insurance. Which would presumably include the Obamacare plan. So keep that in mind too.
posted by katemonster at 6:04 AM on January 20, 2016 [1 favorite]

You're probably not going to find coverage for the lap-band surgery. Every policy I've seen specifically excludes that as elective surgery.

You should be able to purchase separate dental insurance through the ACA marketplace, (or at least I could on the Texas marketplace.)
posted by MsMolly at 10:15 AM on January 20, 2016

A quick internet search for "gastric reduction surgery medicaid new york" suggests that gastric bypass is covered under New York's Medicaid, though there are restrictions and it may be difficult to find a surgeon who accepts Medicaid. These appear to be the national Medicaid eligibility guidelines. I'm afraid I can't answer your other questions. Best of luck!
posted by reren at 5:02 PM on January 20, 2016

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