Behavioral Health Medicaid Advantage Plus (MAP) Carve-In Effective January 1, 2023
Effective January 1, 2023, New York State (NYS) is carving additional Behavioral Health (BH) services into the Wellcare By Fidelis Dual Plus (MAP) plan.
Behavioral Health (BH) Services Carve-In
Services Covered by Medicaid Only
Beginning January 1, 2023, MAP Plans will be required to pay at least 100 percent of the mandated Medicaid rate for Medicaid-only covered procedures delivered to individuals enrolled in MAP Plans when the service is provided by an OASAS and OMH licensed, certified, or designated program.
Medicaid rates are required for the following three categories of services:
- OMH Government Rate Services
- Assertive Community Treatment (ACT)
- Continuing Day Treatment (CDT)
- Comprehensive Psychiatric Emergency Program (CPEP), including Extended Observation Bed (EOB)
- Partial Hospitalization (PH)
- Personalized Recovery Oriented Services (PROS), except the clinic component
- OMH/OASAS Government Rate Services
- Community Oriented Recovery and Empowerment (CORE) Services
- Psychosocial Rehabilitation (PSR)
- Community Psychiatric Support and Treatment (CPST)
- Family Support and Training (FST)
- Empowerment Services – Peer Supports (Peer Supports)
- OASAS 1115 Waiver Demonstration Programs
- SUD Residential Treatment – Per Diem (Stabilization and Rehabilitation - and, upon CMS approval, Reintegration)
Services Covered by Medicare and Medicaid
Beginning January 1, 2023, MAP Plans will pay the “higher of” what Medicare or Medicaid would pay for BH ambulatory services that are reimbursable under both Medicare and Medicaid. With the principle of Medicaid being the payer of last resort, Medicaid is responsible for the remaining balance after the Medicare payment, up to the Medicaid rate if the Medicaid rate for the service is higher than Medicare. Medicaid reimburses 100 percent of the patient cost-sharing responsibility if the Medicare rate is higher than the Medicaid rate. The “higher of” requirement applies to the following services:
- Mental Health Outpatient Treatment and Rehabilitative Services
- Personalized Recovery Oriented Services (PROS) (Clinic component)
- Outpatient Medically Supervised Stabilization and Withdrawal (Detox)
- Outpatient Chemical Dependence (CD) Clinic (aka Outpatient Addiction Rehab)
- Outpatient CD Rehabilitation (aka Outpatient Addiction Day Rehab)
- Opioid Treatment Program
NOTE: If the service and the professional performing the service are allowable under
Medicaid, but not allowable under Medicare, MAP Plans must reimburse the service as a Medicaid-only service at the Medicaid rate. Typically, the practitioner in these programs is not allowable under Medicare, in which case the MAP Plan must reimburse the service at the Medicaid rate.
MAP Care Management
All services must be coordinated by Fidelis Care's Care Manager. Integrated care management for those with Behavioral Health needs will be provided as appropriate. The provider must inform the Care Manager of any identified barriers to maintaining the member’s health.
A corrective plan of action will be implemented to address any issue or concern identified and supportive documentation will be maintained in the patient’s file. Members shall be referred to other participating network providers, unless there is no provider in Fidelis Care's network.
The members must use providers that are participating in the program; out-of-network care must be pre-authorized and arranged by Fidelis Care.
Additional assistance can be provided by the member’s Fidelis Care Nurse Care Manager at 1-800-688-7422.