Managed Care Frequently Asked Question and Answers:

In July and August of 2019, Care Design NY held managed care focus groups in four regions throughout New York State (NYS), including Long Island, Manhattan, Hudson Valley and Capital District/ North Country.

The focus groups were facilitated by a neutral third-party contractor.

The goal of these focus groups was to offer individuals and families the opportunity to share with Care Design NY their thoughts, feelings, concerns, and questions about the anticipated roll-out of managed care in NYS for individuals with intellectual and/or developmental disabilities.

We would like to use the information learned in these sessions to produce meaningful education and outreach materials for individuals and families.

Below are questions discussed during the focus groups along with answers to assist you with information pertaining to managed care.
Q. Who is going to take care of my loved one when I’m gone?
This is a concern raised by individuals and families regardless of whether the overall service system moves to managed care. Care Design NY wants to work with individuals, families and Care Design NY’s Provider Network team to explore creative solutions to address this concern.

In the meantime, individuals and families should continue to build natural supports. The Care Design NY Care Manager will continue to assist with resources in the community i.e.; Guardianship, Special Needs Trust, and Supportive Decision Making

Q. When will NYS make details public? Will there be a public comment period?
Answer: The New York State Office for People With Developmental Disabilities (OPWDD) has publicly stated that the application to become a specialized managed care plan-provider led (SIP-PL) would be forthcoming in the coming months with no defined date. The revised application, if it follows the initial draft disseminated in 2018, will include details about the roll-out.

Given the long delay in circulating the revised application to the public, it is likely that NYS will host another public comment period.

Visit the New York State OPWDD and Department of Health (DOH) websites for information the agencies will post for individuals and families during the transition period. Information can be accessed from the following websites:

  • https://opwdd.ny.gov/opwdd_services_supports/managed_care
  • https://opwdd.ny.gov/sites/default/files/documents/045_Evolution_of_Managed_Care_41119.pdf

We will also keep individuals and families up to date through Care Design NY’s website, social media and other communications.

Q. Will we be able to keep our Care Coordination Organization Care Manager?
Assuming NYS follows its initial draft application, the CCO Care Manager will most likely be able to continue to support the individuals they are supporting today.
Q. Will managed care oversee waiver programs?
Managed care will include the waiver services to create an integrated (meaning that healthcare and Developmental Disabilities (DD) services will be under one plan) service model. The initial application had waiver services included, but it is unclear at this time, if the waiver services will be included when managed care launches or after a certain period of time.
Q. Will we be able to choose our own specialists when needed and will second opinions be allowed?

This will depend on the plan that the individual chooses to utilize.

We will be updating individuals and families on the plans that will be available and ensure they have all the information needed to make an informed decision about the managed care plan that is right for them. Your Care Manager will be able to assist you should you have any questions when reviewing the plans. This includes a review of the doctors, specialists, dentists, etc. in the plan’s Provider Network.

Q. Will dental be covered?
Yes, dental services will be part of the services offered.

Each managed care plan will be expected to build a Provider Network, including dentists. Once we have the information for each managed care plan, we will ensure that the information is shared in a timely manner so that informed choices can be made.

Q. Can you opt-out? Can you withdraw (what are the change of events)?
Withdrawing from managed care is an option only during a voluntary enrollment period. If NYS follows its initial application, there will be a period of time for voluntary enrollment but enrollment in managed care will eventually be mandatory.

We will not have the final details on this until the revised application is released by NYS.

Q. Will doctors in ER/hospital participate in managed care or will we get billed?
Answer: The ER/hospital will bill the plan as long as services are covered through the plan.
Q. Will the residential facility pick the managed care plan or will individual?
The individual or the individual’s authorized representative will pick the managed care plan they would like to have once they have reviewed all their options with their Care Manager.
Q. Will managed care determine when my loved one is allowed to go to the doctor?
The managed care plan, through care coordination, will work with individuals and families to develop a Life Plan that is right for them including seeing doctors that are critical in carrying out the plan, including wellness and emergencies.
Q. How does the Life Plan factor in? Can the managed care company reassess at any time?
The process and requirements for developing and updating a person’s Life Plan are not expected to change. The Care Manager will continue to review with the individual/family and their team.
Q. Will out of state services be covered?
It is unclear what NYS will require of managed care plans as it relates to out of state services. This could also depend on the plan that is chosen.

Once we have the information for each managed care plan, we will ensure that the information is shared in a timely manner so that informed choices can be made.

Q. How will advocates learn to advocate?
Answer: Individuals and families learning to advocate for themselves or their loved one is always needed regardless of whether services are funded through fee-for-service or managed care. Advocacy is also part of the role of the Care Manager to ensure that individuals get the supports and services they need. Because this is all funded through Medicaid, individuals have rights if services are denied, reduced or modified.

You should reach out to your Care Manager to discuss this further. We will also add this topic to future webinars that we conduct for individuals and families throughout the year. Individuals and Families can also connect with Advocacy Groups i.e. Parent to Parent and Self Advocacy Association of New York State (SANYS).

Q. Will Self-Direction survive through this change?
Yes, Self-Direction will be part of the managed care benefit package when there is full integration of services (health, long term care and OPWDD supports and services).
Q. Will Medicare kick in at some point?
Individuals who have Medicare will continue to have the choice whether to participate in managed care but only as it relates to their health care needs.

However, Medicare doesn’t pay for OPWDD supports and services, only Medicaid. Therefore, when the OPWDD supports and services are included in the managed care benefit package, the expectation is that individuals will need to enroll in a managed care plan to receive those services once there is mandatory enrollment.

Q. Is the Provider Network broad/strong enough?
Like the initial application, the revised one will include NYS, SANYS, and the Federal government’s expectations regarding the plan’s Provider Network. Part of NYS approval process will be to ensure that each plan meets the requirements laid out in the application. This doesn’t mean all of your providers will be in a plan’s network. You will need to work with your Care Manager to review as part of your decision as to which plan to join.
Q. What happens if a person has private insurance?
We will need to see how NYS addresses this, but they will likely treat it like Medicare (see above) as long as the private insurance is paying 100% of the cost (which means Medicaid is not paying) for any of the health care costs.

Also, similar to Medicare, private insurance does not pay for OPWDD supports and services. Therefore, when the OPWDD supports and services are included in the managed care benefit package, the expectation is that individuals will need to enroll in a managed care plan to receive those services once there is mandatory enrollment.

Q. Will there be ramifications for people who need more services/supports?
There shouldn’t be! A managed care plan is expected to develop and fund a Life Plan that meets the needs of the individual with the Life Plan being regularly updated to ensure that any change(s) needed will be addressed.
Your Care Manager and Care Design NY team will be available to assist you with any questions you may have regarding managed care. If you have any questions you can reach out to your Care Manager or email your questions to: This email address is being protected from spambots. You need JavaScript enabled to view it..

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