As of October 1, all HIV-positive clients who are on Medicaid will be mandated by New York State to enroll in a Medicaid Managed Care plan. The mandate applies to clients who are not currently on a plan, have what is called “a spend down” or are not dually enrolled in Medicaid and Medicare. Up to this point, clients could opt into or out of a managed care plan.
“What this really means is that clients will have to pick a primary care provider,” said Liz Lacy, ARCS’ Director of Client Services. “Before, clients could go to any provider who accepted Medicaid, but now they will need to stick with their chosen primary care provider and get prior authorization for tests, specialty care and specialists through primary care.” The biggest advantage is that more specialists accept Medicaid managed care plans than regular Medicaid, which should result in easier and better care for ARCS clients. Most of them use their infectious disease specialist as their primary care provider.
“A disadvantage is that clients will have to get used to coordinating their medical care through their primary care provider,” Lacy said. Clients may change their PCP at any time, or even the managed care plan within certain time frames, but this can be overwhelming for people without experience in navigating this complex system. “But one of our core services is to help them access these government programs, so our case managers will guide them through the process. Right now we are educating our clients and helping them to choose a plan, because if they ignore the mandate they will be auto-assigned to a plan that may not be best for them.”
Lacy also points out some uncertain aspects of the new program. “We’re not yet sure what will happen with pharmacy benefits, which will be lumped into the Medicaid managed care plan.” Previously, pharmacy benefits were paid directly by Medicaid itself. The managed care companies are trying to figure out how to fit the cost of expensive antiretroviral medications into their operations. “They may allow certain medications but not others, or create different tiers, which would then force doctors to prescribe different medications to our clients. Right now it’s a gray area.” New York State’s ADAP program would not be available as a stop-gap measure, since a client on Medicaid is not eligible to receive ADAP except in cases where spend downs need to be met, but not to cover other medications or services.
“So far our clients are coping with the change and we are steering them through it,” Lacy said.