Info re: Default Enrollment Issue

May 14, 2021

NYS Council members

This is the transmittal going out to MMC plans, including mainstream,  HARP and HIV Special Needs plans re: requirement to APG government rates.

I will collect your specific questions as you send them to me and submit to OMH next week.

Hooray for all!


From: “Buckley, Shannon (OMH)” 
Date: May 14, 2021 at 3:12:58 PM EDT
To: “Katagiri, Joe (OMH)”
Cc: “Schaefer, Lynne (OMH)” 
Subject:  Duals Reimbursement in MMC

To Medicaid Managed Care plans (MMCPs) including Mainstream Medicaid Managed Care, Health and Recovery Plans and HIV Special Needs Plans:

Enrollees who become eligible for Medicare have remained in their MMCP during the public health emergency, unless opting to change their enrollment. Some of these enrollees have enrolled in their MMCP’s aligned Medicare D-SNP and remained in their MMCP through the Integrated Benefits for Dually Eligible Enrollees program.  

This is a reminder that Chapter 57 of 2019 of the Laws of New York and Section 21.19 (f) of the Medicaid Managed Care/HIV Special Needs Plans/Health and Recovery Plan Model Contract requires that MMCPs reimburse hospital-based and free-standing behavioral health clinics at an amount equivalent to the payments established for such services under New York State’s Medicaid ambulatory patient group (APG) rate-setting methodology. Therefore, when processing claims for dual eligibles for services provided by behavioral health clinics:

1) MMCPs are required to coordinate benefits with Medicare primary coverage when applicable, and

2) MMCPs are to ensure reimbursement to such behavioral health clinics is configured to pay up to the higher of the Medicaid APG payment amount or the Medicare rate. 

This represents total reimbursement to the provider; members in MMCPs should not experience Medicare cost sharing responsibility outside of the pharmacy benefit.

If you have any questions, please contact