Office for People With Developmental Disabilities

Managed Care FAQs

Questions and Answers:

What is managed care?

Managed care is a payment system in which a Managed Care Organization (MCO) receives money that will be paid to a group or network of providers to plan and deliver all of a person’s medical, behavioral and developmental disabilities services and supports.

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How is this different than the current system?

Currently, providers of services are paid by the Office for People With Developmental Disabilities (OPWDD) for the “units” or hours of service they provide for a person. This is called “fee-for-service.” In managed care, Managed Care Organizations contract with the state to manage cost, utilization and quality of services through a network of providers to meet the needs of people (members) who have selected that MCO. In addition, New York State (NYS) plans to implement a system of “value-based payment” through Managed Care Organizations to reward providers to deliver high quality supports and explore new ideas for providing better services.

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What are value-based payments?

In OPWDD’s new managed care environment, value-based payments are defined as a payment system between a Managed Care Organization and its providers of services to financially reward providers to deliver high quality services based on a person’s Life Plan while achieving positive outcomes that help people reach their goals. 

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Why is the Office for People With Developmental Disabilities (OPWDD) moving the system to managed care?

Managed care makes it easier for OPWDD to ensure that services are helping people. Managed care gives OPWDD a way to measure how well a provider meets a person’s needs (their outcome) rather than just measuring that a service was delivered. It also helps people receive services they need from OPWDD and other important health and behavioral health services.

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Can you provide examples of how managed care will help people get better services?

  • Managed care will help avoid unnecessary emergency room visits and hospital stays by identifying the underlying (root) issues and improving care coordination to prevent unnecessary use of emergency rooms or hospitalization. 
  • Better preventive dental care is critical to a person’s health and welfare. Managed care will improve access to dental care because dentists and specialists will be part of the plan’s network of providers. 
  • Managed care will help improve access to diagnostic screenings and preventive services that will now be available through its network of providers.
  • Managed care will expand access to and coordination of community services provided by different New York State agencies. 

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How will managed care work?

Just like the current system, people with developmental disabilities who are new to services will work with OPWDD Regional Office staff to determine their eligibility for Medicaid Home and Community Based Services (HCBS) Waiver services and supports, and to select a Managed Care Organization (MCO). 

A care manager will assist the person with developmental disabilities and their family and/or advocates in the person-centered assessment and planning processes. 

After the assessment is complete, they will develop the Life Plan. The Life Plan serves as the basis for outlining the supports a person needs and his or her desired outcomes. 

The Managed Care Organization then offers the person access to a network of providers who will deliver the services. The MCO will also provide opportunities for self-direction. 

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Are people with developmental disabilities enrolled in managed care today?

Yes. The Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD) demonstration program in the New York City metropolitan area is a managed care program for 1,100 people. There is also a Program of All-Inclusive Care for the Elderly (PACE) that provides managed care services to elderly people with and without developmental disabilities. Both of these managed care plans are run by organizations with experience serving people with intellectual and developmental disabilities (I/DD). In addition, there are currently over 25,000 people with developmental disabilities enrolled in the mainstream managed care program for their non-OPWDD services.

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When will managed care be fully implemented?

Managed care for people with developmental disabilities will be implemented in 2021, and services will be carefully monitored as they gradually transition between now and full implementation.

Initially, people will begin enrolling in managed care on a voluntary basis as early as 2019, meaning a person chooses whether they would like to be enrolled in managed care. 

Beginning in 2021, people eligible to enroll and who are receiving OPWDD services will begin to have to choose a Managed Care Organization to manage their supports. 

To ensure a smooth transition, OPWDD will monitor the progress of managed care programs and make adjustments as needed before making enrollment mandatory.

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How are Managed Care Organizations (MCO) different from Care Coordination Organizations (CCO)?

In NYS, Managed Care Organizations were created to expand health care services for its citizens and provide them with greater choice in health care options. Medicaid Managed Care Organizations contract with the state to manage the planning, delivery and costs of healthcare services for people who select that managed care plan. People with developmental disabilities in NYS will now access managed care to plan and deliver all of their health care, behavioral health and developmental disability services through their plan’s network of providers.

Medicaid managed care plans must—

  • Have a full network of providers to serve individuals and families
  • Ensure that individuals and families have input and a strong voice in their supports
  • Address health, safety and clinical needs
  • Meet performance and quality management standards
  • Secure private information

The Care Coordination Organization provides care management services including a person-centered assessment of a person’s needs and choices, and assists in the development of a Life Plan that identifies the supports a person needs and their desired outcomes. The care manager coordinates comprehensive developmental disability, medical and behavioral services for the person while the Managed Care Organization will authorize the person’s services and provide access to a network of providers responsible for the delivery of the services in the Life Plan.

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What is a SIP-PL?

Specialized Intellectual and Developmental Disabilities Plan – Provider Led (SIP-PL) is a term used in technical documents to describe a Managed Care Organization that is authorized to provide specialized services and supports for people with developmental disabilities. These organizations are led by OPWDD-certified providers with a history of commitment to people with intellectual and developmental disabilities.

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Will I still be able to use the same providers that now provide my services?

You will be able to use the same providers under managed care if they participate in the Managed Care Organization’s network. A person can choose to enroll in a managed care plan that includes their current providers as part of its network. 

Even if your provider is not a part of the MCO’s provider network, the MCO may use a Single Case Agreement to contract with non-participating providers to meet your clinical needs when in-network services are not available. There are also special rules for residential services that allow people to receive residential services from their current providers as long as the need is identified in their Life Plan. 

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What happens if I am not satisfied with my services?

If you are not satisfied with your services, you can talk with your Managed Care Organization and/or with your care manager to review your Life Plan to determine if a change is needed. 

If you are not satisfied with your provider, you have the right to select a different provider within the Managed Care Organization’s network. 

If you are not satisfied with your Managed Care Organization, you can choose another managed care plan. Also, you can file a complaint with the Managed Care Organization and appeal the Managed Care Organization’s decision(s) about your care.

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What happens to the supports I am currently receiving while I make the change to managed care? Will my services decrease?

Your services and supports will not change during the transition to managed care. The Managed Care Organization contract requires “Continuity of Care,” which means that your level of services and supports does not change just because you are enrolled with a Managed Care Organization. However, over time your services may change based on your changing needs and choices. 

The person-centered planning process, with individuals and families fully involved in planning and approval of the plan, will continue to drive any changes. 

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What is the role of the Coordinated Assessment System (CAS) in Managed Care?

The Coordinated Assessment System (CAS) is a person-centered assessment tool used to assess the strengths, needs and interests of people with developmental disabilities. The CAS looks at a person’s decision-making, routine daily activities, communication skills and behavior. The information helps the person and care manager to develop the Life Plan for person-centered services and supports. Over time, as the CAS is more fully implemented, the CAS will establish a determination of need through a scoring system and will play a role in identifying the level of service needed by a person.

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How will positive outcomes be measured?

OPWDD is currently working with stakeholders to identify the standards that will define health, quality of life and personal positive outcomes for people with developmental disabilities, and how these outcomes will be measured. OPWDD and stakeholders are working to identify “positive” outcome measures to improve quality of life, informed choice, self-direction and advocacy and/or community inclusion.

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How does managed care work for someone who is in self-direction?

People that are self-directing their services will continue to experience the same flexibility and control that they have now. Just as it is now, a person’s Personal Resource Account (PRA) amount will be based on a standard needs assessment and will be set by the state. People who self-direct, and their families, will continue to have brokers and fiscal intermediaries to assist them and a care manager to help plan for all their needs. 

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Where can I learn more?

OPWDD is fully committed to hearing from you and responding to your concerns as we move forward. Please feel free to reach out to your regional office, call 1-866-946-9733 or email: [email protected] to ask questions or share your feedback. 

Make sure to Join the Conversation by signing up to receive important updates from OPWDD on the homepage of our website.

 

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