An Introduction to New York's HIV Special Needs Plans

An HIV Special Needs Plan, or HIV SNP (pronounced "HIV snip"), is a new kind of Medicaid plan for people with HIV in New York State. Medicaid is the government health insurance program that provides coverage for people with limited incomes. (Medicaid is not the same as Medicare, which is a federal health insurance program that provides for people who are elderly or disabled.) Medicaid is the source of healthcare coverage for more than 65% of New Yorkers with HIV/AIDS.

Why Were Medicaid HIV SNPs Created?

When it began, Medicaid was a fee-for-service program. This means that the government pays providers, like doctors, clinics and hospitals, for each of the services they give to people with Medicaid. In most states, Medicaid has been shifting to a managed-care system in recent years. In a managed care Medicaid plan, the government pays a health plan a certain dollar amount for each Medicaid beneficiary enrolled, and in return the plan provides for most of the enrollee's care. This change was designed to help control costs within the Medicaid system.

New York's HIV SNPs are a type of Medicaid managed care plan. But, they are only for people with HIV and their children. These special plans were proposed to coordinate the complex array of medical and social services needed to help support the health of people living with HIV. SNPs will be expected to manage HIV disease comprehensively by offering medical care and supportive social services, like treatment education and adherence programs, all under the supervision of a case manager. Medical and social service providers specializing in HIV have been forming networks and contractual relationships among themselves in preparation for the SNPs. As New York pioneers this HIV-specific managed care plan, Medicaid programs in other states will be watching closely.

In New York State, as in many other states, managed care is changing from a voluntary to a mandatory system. New Yorkers with Medicaid have been receiving notices that they must choose a Medicaid managed care plan. However, people with HIV are exempt from this shift to mandatory managed care and, for now, they can choose to stay in traditional, fee-for-service Medicaid.

Will People with Medicaid and HIV in New York Have to Join an HIV SNP?

Initially, New York's HIV SNPs will be voluntary. This means that people with HIV who have Medicaid can either stay in regular Medicaid, choose a "mainstream" Medicaid health plan, or choose an HIV SNP. They will not lose their Medicaid benefits if they do not enroll in an HIV SNP.

But sometime in the next few years, managed care for New Yorkers with HIV may become mandatory. This means that people with HIV who receive Medicaid may have to choose an HIV SNP or a Medicaid "mainstream" health plan, and won't be able to stay in fee-for-service Medicaid. Some groups of people, such as those who are homeless, will still be exempt from mandatory managed care and will be allowed to stay in traditional Medicaid if they wish.

What Are the Differences Between Traditional Medicaid, "Mainstream" Medicaid Managed Care Plans, and HIV SNPs?

HIV SNPs are different from traditional Medicaid in several ways. First of all, they are managed care plans. Like "mainstream" Medicaid health plans that already serve people with and without HIV, HIV SNPs receive a certain amount of money from the government for each person enrolled. In turn, HIV SNPs provide their enrollees with most of their healthcare.

Here are some similarities and several important differences:

1. Benefits: People in HIV SNPs and Medicaid managed care plans get all the same benefits as people in traditional Medicaid. Most of the benefits are given directly by the SNP, but others are given outside the SNP. For example, a SNP may provide addiction counseling directly, but refer a client to an outside methadone program.

2. Case Management: An HIV SNP is supposed to create an "umbrella" of services to meet the special needs of people with HIV and their children. So, HIV SNP enrollees will have case managers to help coordinate all of the medical and social services that members should receive.

3. Providers: In traditional Medicaid, people can see any providers (doctors and hospitals) who take Medicaid. In an HIV SNP, enrollees can usually only go to providers who participate in the health plan. These providers make up the health plan's network.

4. Primary Care Providers: Members of an HIV SNP have one doctor who is a primary care provider, or PCP. The PCP coordinates the enrollee's medical care, and if the enrollee wants to see a specialist, she or he usually has to get a referral from the PCP. In an HIV SNP, all primary care physicians are "HIV specialists," which means they have at least a minimal amount of training and experience in treating people with HIV/AIDS.

5. Specialists: People in traditional Medicaid can see any specialist who takes Medicaid. People in "mainstream" Medicaid managed care plans, including SNPs, will usually need a referral from their primary care physicians and can only see specialists in the plan's network.

Questions? Contact GMHC's Managed Care Coordinator: (212) 367-1126.

Be Aware of Barriers to Care: Family Planning Services

HIV SNP enrollees are supposed to be able to get family planning and reproductive health services from any Medicaid provider, whether or not the provider is a part of the SNP's network. Enrollees do not need a referral from their PCP or approval from the plan. The SNP must tell every enrollee of childbearing age about this right, and must give her a list of family planning providers.

One network that has applied to become an HIV SNP in New York is Fidelis Healthcare, a Medicaid health plan sponsored by the Catholic Church. Because Catholic healthcare directives forbid offering most family planning services, the Fidelis SNP must refer its enrollees to out-of-network providers. In the past, religious healthcare providers have sometimes refused to inform beneficiaries about the full range of family planning options and some have refused to supply the mandated referrals or have created other barriers to care. Enrollees in the Fidelis SNP should be especially careful to ensure they are offered comprehensive care and the full range of services.

Family planning services include:

• Contraception

• Sterilization

• Screening, diagnosis, and referral to participating providers for pregnancy

• Medically necessary abortions and, for NYC residents, elective abortions

• Pap smears

• Pelvic and breast exams

• STD testing and treatment

These services include all necessary education and counseling. Family planning services also include pre- and post-test HIV counseling and blood testing, when it's part of a family planning appointment. HIV SNPs have to provide counseling for all pregnant women, prenatal care including treatment to prevent transmission of HIV to the baby, plus testing to diagnose or rule out HIV infection in exposed infants. Minors have the same right to family planning services in HIV SNPs as adults. The plan must keep all information about family planning confidential, for both adult and minor enrollees.

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