Navigating Managed Medicaid

We know that finding a therapist near you in or near Garden City NY of Long Island who takes your Managed Medicaid plan with Fidelis Healthfirst or Community Plan is important in your care and we are happy to be able to provide services under these plans.

​Managed Medicaid Plans Accepted:   Fidelis, HealthFirst, UHC Community Plan

​The following is general information to best of our knowledge about obtaining Managed Medicaid plans but please be to sure to take into account all your benefits and circumstances and consult with others to see if this is best for you.

Navigating Managed Medicaid

Have you had a significant life change that has or may impact your insurance? If so one of these may apply to you:

Scenario 1:

At times when you apply through the state or another entity for other types of benefits, the office of Medicaid or another entity may by default change your insurance back to straight Medicaid. This can happen during renewals, when states try to streamline services, or when your other benefits or income changes. This can happen because Medicaid programs must coordinate benefits with other entities and also because the choice of a more specific plan is yours to make. The challenge is that this default change to straight Medicaid can limit your provider network and access to specialized care, which are typically managed through a Managed Medicaid plan. In order to see a provider here see help getting Managed Medicaid.

Scenario 2:

If you have had a recent change of income, may no longer be eligible to be on another's insurance plan, or have another qualifying life event, you may be eligible for a Medicaid managed care or essential insurance plan. If so, you could receive full or significant coverage for therapy visits here if selecting a plan we are in network with. In order to see a provider here see help getting Managed Medicaid.

Scenario 3:

You never had Managed Medicaid and were automatically assigned NY Medicaid or Straight Medicaid. This may not be an error, but as mental health providers under our provider type we are only able to accept Managed Medicaid Plans which in the simplest of terms means that a specific insurance company would be managing a portion of you Medicaid benefits and access to certain care and providers such as us. Read on for help with getting a Managed Medicaid Plan we accept.

Help obtaining Managed Medicaid

It is best to call the number through the NYS health exchange (1.855.355.5777) and let them know you believe you may qualify for a Medicaid level or Essential plan or already have Medicaid but want to choose a managed Medicaid plan. These plans are not always viewable on the main website. 

The Medicaid plans we accept are Healthfirst, UHC Community, and Fidelis.

Here is the link to the New State of Health website to look into enrolling and questions you might have: https://info.nystateofhealth.ny.gov

You may want to consider the following when changing your insurance:

-Make sure any necessary medical treatment you need such as providers, medications would be covered under the new plan. Our clients thus far have not had issues when switching but every situation is unique.

-Discuss any impact on co-insured family members if applicable

-Ask if there would be any deductible or copay for 'routine professional individual mental health visits'. Medicaid and Essential plans usually are $0 to $15 but higher level essential plans may be more or have a deductible.

-If you have insurance through your job and are considering opting out of that and getting a plan through the exchange, make sure to examine compare the effects of this.

-The NYS of health assigns insurance agents to help clients navigate benefits and you can view full benefit descriptions online before choosing.

Thank you and we hope this is of help.

Navigating Insurance Deductibles, Copays and Coinsurances

 Health insurance terms can be confusing and overwhelming for clients and providers alike. Here we try our best to explain some basics.

What is a deductible?

​For mental health coverage, a deductible (if it applies) is the amount you pay out-of-pocket for covered services before your insurance company starts to share the cost. Once you meet your deductible for the plan year, you will likely only owe a copayment, coinsurance, or percentage for future sessions.

Mental health deductible:

The annual cost you pay first: The deductible is a set dollar amount that you are responsible for paying each year before your insurance starts to assist. For example, if your plan has a $1,500 deductible and a $30 copay, you will pay 100% of your mental health care costs until you've paid $1500 for the year and before your insurance covers part of the cost. 

This does NOT mean that for a session/one service you pay $1200. It means that you pay the full contracted amount for the service each session ($80 for example) until you have met the deductible for the plan year. Additionally if you attend 4 sessions and pay $320 towards them and then stop therapy, you would NOT need to pay further towards the deductible as it applies to USE of services.

Example: 

In-network therapist's contracted fee: $80 per session

Deductible: $1200

Copay: $30

You would pay $80 per session for 15 sessions ($1200) and then the cost would be reduced to $30 per session for the remainder of the year.

Deductibles reset annually: Your deductible resets at the start of each plan year. This means you will need to meet it again when the plan year renews before your insurance begins to cover costs again.

After meeting your deductible: Once you've paid the full deductible amount, your insurance will begin to cover a portion of your therapy costs. At this point, you will likely transition to paying only a copayment or coinsurance (the example of $30).

*Does not include premiums: The deductible is different from your monthly insurance premium. Your premium is the fixed amount you pay to your insurance plan, regardless of whether you use any services.

What are copays and coinsurances?

This pertains to the amount you pay aside from any deductible that may or may not apply. 

Copayment: A fixed dollar amount you pay for each session ($30)

Coinsurance: A percentage of the cost you pay for each session (10% so for example $10 percent of $80 would be $8.00).

While most insurance plans have EITHER a copay OR deductible it is possible for them to apply both and depends on your plan.

Another example:

In-network therapist's contracted fee: $80 per session 

Annual deductible: $1200

Coinsurance: 20% ($16)

Here’s how your costs would be calculated:

First 15 sessions ($80 x 15 = $1200): You would pay the full $80 for each session. By the 16th session and for the rest of the plan year your 20% coinsurance kicks in. So, for the remainder of the year you pay $16.

Some plans either do not have deductible at all or the deductible does not apply to mental health services. When you start therapy here we get a quote from your insurance regarding deductible and copay/coinsurance and if your deductible applies.

 

Thank you and we hope this is of help.