Full Answer
What does MMC stand for in Medicaid?
Medicaid Managed Care (MMC) Overview: Managed Care is a general term used to describe any health insurance plan or system that coordinates care through a primary care practitioner or is otherwise structured to control quality, cost and utilization, focusing on preventive care.
What is an MMC in NYS?
Medicaid Managed Care (MMC) provides Medicaid state plan benefits to enrollees through a managed care delivery system comprised of Managed Care Organizations (MCOs). Authorized under Section 364–j of Social Services Law (SSL) Contracts and pays the participating providers directly for services Are paid a capitated rate (per member/per month) by NYS
What is an NYS Medicaid managed care plan (MMCP)?
NYS Medicaid Managed Care Plans (MMCP): An individual must be: Are HMOs, PHSPs, or HIV SNPs Certified under Article 44 of the Public Health Law by the Department of Health in conjunction with the Department of Financial Services
Are you eligible to enroll in a MMC plan?
Most Medicaid eligible individuals are required to enroll in a MMC Plan unless otherwise exempt or excluded. Medicaid eligibility must be established first. An exemption means that a consumer is not required to join a MMC Plan unless he or she so chooses. Exemptions are outlined in NYS Social Services Law section 364–j (3) (d).
What does MMC mean in health insurance?
Medi-Cal Managed Care.
What is the purpose of managed care organizations?
The purpose of managed care is to enhance the quality of healthcare for all patient populations. Managed care revolves around the collaboration of health insurance plans and healthcare providers. Managed Care includes healthcare plans that are used to manage cost, utilization, and quality.
What is an example of a managed care plan?
A good example of a managed care plan is an HMO (Health Maintenance Organization). HMOs closely manage your care. Your cost is lowest with an HMO. You are limited to seeing providers in a small local network, which also helps keep costs low.
Is managed care the same as Medicare?
Managed care plans are also referred to as Medicare Part C (Medicare Advantage) plans. These plans cover everything original Medicare does, and they often cover additional services as well. For example, original Medicare doesn't cover routine dental care, but many managed care plans do.
What are the disadvantages of managed care?
What Are the Disadvantages of Managed Care?It limits care access for those who do not have insurance or provider coverage. ... The rules of managed care are extremely rigid. ... People are forced to advocate for themselves. ... Patients often come down to dollars and cents. ... There is a loss of privacy.More items...•
What are the 4 major goals of managed care?
Purchasers with vision can use managed care arrangements to achieve specific goals: improve access to care, enhance the quality of care, better manage the cost of care, increase the effectiveness of care, and facilitate prevention initiatives.
What is the most popular form of managed care plans?
PPOs are also the most popular form of Managed Care (Health Insurance In-Depth). Point of Service (POS) medical care limits choice, but offers lower costs when compared to HMOs and PPOs. Generally an individual chooses a primary health care physician within a health care network.
What are the advantages and disadvantages of managed care?
Benefits of managed care include patients having multiple options for coverage and paying lower costs for prescription drugs. Disadvantages include restrictions on where patients can get services and issues with finding referrals.
What are the four types of health care plans?
Types of Health Insurance Plans: HMO, PPO, HSA, Fee for Service, POS.
What is the difference between Medicare fee for service and managed care?
Under the FFS model, the state pays providers directly for each covered service received by a Medicaid beneficiary. Under managed care, the state pays a fee to a managed care plan for each person enrolled in the plan.
What does managed care mean in healthcare?
Managed Care is a health care delivery system organized to manage cost, utilization, and quality.
What are the 6 managed care models?
Terms in this set (6)IDS (Intregrated Delivery System. Affiliated provider sites that offer joint healthcare. ... EPO (Exclusive Provider Organization. ... PPO ( Preferred Provider Organization) ... HMO (Health Maintence Organization) ... POS (Point of Sale) ... TOP (Triple Option Plan)
What is a Medigap plan?
A Medigap plan, also known as Medicare supplement insurance, is optional coverage you can add to original Medicare to help cover out-of-pocket costs. Medigap plans can help you pay for things like: coinsurance costs. copayments. deductibles. These aren’t a type of managed care plan.
What is PFFS in medical?
Private Fee-for-Service (PFFS). A PFFS is a less common type of managed care plan. PFFS plans don’t have networks. Instead, for a present price, you can see any doctor who contracts with Medicare. However, not all providers accept PFFS plans. Special Needs Plan (SNP).
What is Medicare Advantage?
Sometimes referred to as Medicare Part C or Medicare Advantage, Medicare managed care plans are offered by private companies. These companies have a contract with Medicare and need to follow set rules and regulations. For example, plans must cover all the same services as original Medicare.
What is the difference between HMO and POS?
The difference is that an HMO-POS plan allows you to get certain services from out-of-network providers — but you’ll likely pay a higher cost for these services than if you see an in-network provider. Private Fee-for-Service (PFFS). A PFFS is a less common type of managed care plan. PFFS plans don’t have networks.
How much does Medicare cost in 2021?
Most people receive Part A without paying a premium, but the standard Part B premium in 2021 is $148.50. The cost of your managed care plan will be on top of that $148.50.
What is Medicare managed care?
Medicare care managed care plans are an optional coverage choice for people with Medicare. Managed care plans take the place of your original Medicare coverage. Original Medicare is made up of Part A (hospital insurance) and Part B (medical insurance). Plans are offered by private companies overseen by Medicare.
What is a SNP?
Special Needs Plan (SNP). An SNP is a managed care plan designed with a specific population in mind. SNPs offer additional coverage beyond a standard plan. There are SNPs for people with limited incomes, who are managing certain conditions, or who live in long-term care facilities.
What is managed care?
Managed Care is a general term used to describe any health insurance plan or system that coordinates care through a primary care practitioner or is otherwise structured to control quality, cost and utilization, focusing on preventive care. Medicaid Managed Care (MMC) provides Medicaid state plan benefits to enrollees through a managed care delivery ...
What is the code for Medicaid certified?
Qualified by the Department of Health to provide Medicaid services Meet federal regulations at 42 CFR 438.
Do you have to enroll in MMC?
Eligibility Requirements: Most Medicaid eligible individuals are required to enroll in a MMC Plan unless otherwise exempt or excluded. Medicaid eligibility must be established first. An exemption means that a consumer is not required to join a MMC Plan unless he or she so chooses.
What is Medicare Part B?
Medicare Part B covers individual and group therapy services to diagnose and treat mental illness. The Part B coverage usually requires a physician referral for mental health care and is based on a mental health diagnosis.
Does MA offer chiropractic care?
MA plans may choose to offer routine chiropractic services as a supplemental benefit as long as the services are provided by a state-licensed chiropractor practicing in the state in which he/she is licensed and is furnishing services within the scope of practice defined by that state’s licensure and practice guidelines. The routine services may include conservative management of neuromusculoskeletal disorders and related functional clinical conditions including, but not limited to, back pain, neck pain and headaches, and the provision of spinal and other therapeutic manipulation/adjustments.
What is significant financial risk?
Substantial financial risk occurs when risk is based on the use or costs of referral services, and that risk exceeds a risk threshold of 25 percent of potential payments. (Payments based on other factors, such as quality of care furnished, are not considered in this determination.)
What happens if a MA organization suspends a contract with a physician?
An MA organization that suspends or terminates a contract with a physician because of deficiencies in the quality of care must give written notice of that action to licensing or disciplinary bodies or to other appropriate authorities.
What is primary source verification?
A “primary source” is an organization or entity with legal responsibility for originating a document and ensuring the accuracy of the information it conveys. Primary source verification may be achieved through the use of industry-recognized verification sources. The nationally recognized accrediting organizations specify which sources they consider to be appropriate primary sources for verifying credentials. In some instances, except for licensure, a secondary source will be considered acceptable provided that the secondary source verifies the information from the originator. If the MA organization uses one of the primary sources identified by one of these nationally recognized accrediting organizations, CMS will consider that source acceptable. If questioned, the MA organization should be able to reference which organization identified that source. In addition, although the National Practitioner Data Bank (NPDB) does not have any legal responsibility for issuing a document, it is generally considered an appropriate source of verification by most private accrediting organizations as well as by CMS.
What is the OIG list?
The Office of the Inspector General (OIG) maintains a sanction list that identifies those individuals found guilty of fraudulent billing, misrepresentation of credentials, etc. The MA organizations employing or contracting with health providers have a responsibility to check the sanction list with each new issuance of the list, as they are prohibited from hiring, continuing to employ, or contracting with individuals named on that list. The MA organizations should check the Office of the Inspector General (OIG) Web site at http://www.oig.hhs.gov/fraud/exclusions/list of excluded.html for the listing of excluded providers and entities. The OIG has a limited exception that permits payment for emergency services provided by excluded providers under certain circumstances. See
What happens if an organization declines to include a provider or group of providers in its network?
As noted directly above, if an MA organization declines to include a given provider or group of providers in its network, it must furnish written notice to the affected provider(s) on the reason for the decision.
What is the MA organization?
The MA organization must establish a formal mechanism to consult with the physicians who have agreed to provide services under the MA plan offered by the organization regarding the organization’s medical policy, quality assurance/improvement programs and medical management procedures and ensure that the following standards are met:
How long can a physician be out of Medicare?
If a physician or other practitioner opts out of Medicare, that physician or other practitioner may not accept Federal reimbursement for a period of 2 years . The only exception to that rule is for emergency and urgently needed services where a private contract had not been entered into with a beneficiary who receives such services. See
