The Gold Choice Enrollment Guide provides
step by step instructions for enrollment. The document is
available below, and will soon be available for download
Gold
Choice: A Brief History
Gold
Choice PCMPIIA, as it is known today, was born in 1994 due
to the efforts of many fine individuals and organizations
that saw a need for a Medicaid Managed Care Program for
recipients with special needs. This population consists
of Medicaid beneficiaries who are chronically and persistently
mentally ill and or in substance abuse treatment, who have
historically experienced poor coordination of care.
In 1994
a small but motivated team of individuals set to the task
of setting up such a program. it was agreed that three primary
long-term goals must be met in order to succeed in such
an undertaking
- First
and foremost, access to and availability of primary and
acute medical health care services must be enhanced
- Quality
of care within the program must be ensured.
- A
cost-effective model must be established.
Within
two years (in conjunction with UB Family Medicine, Inc.)
the GOld Choice team established the following:
- A
network of primary care providers
- Procedures
for enrollment, disenrollment, and managed care program
transfers, provider change protocol, grievance/members
rights protocol, and marketing and education practices.
- A
management information system utilization reviews protocol,
and quality assurance protocol.
Once
orientation, training, and educational sessions with area
special care agencies were in place, Gold Choice was ready
to being enrolling members. In the first months Gold Choice
went from 2 members to 12, to processing over 800 applications
per month. Today Gold Choice has over 4,000 enrollees with
200 applications being processed monthly.
Gold
Choice continues to work towards structuring a seamless
health care system, which facilitates and promotes communication
between it's two member organizations: primary care and
specialty care.
PCMP:
Physician Case Management Program
The primary
care provider is responsible for the coordination of medical
care for Gold Choice members. This includes referring members
for specialty care and providing authorization for those
services. Services not authorized by the PCP are not compensated
by Medicaid. The provider is responsible for providing 24-hour
access to care on a non-emergent level. Mental health and
substance abuse services are to continue to be provided
by the special care agency without a referral from the PCP.
Role
of Case Management:
Coordination of Services
The mission
of the GOld Choice Case Management Department is to coordinate
access to medical services and link consumers to additional
special/psychological support services. This is done by
providing dedicated staff members to work one-on-one with
clients, family members and community based providers.
List
of Services
Services
PCP is responsible for providing:
- On
call services 24 hours a day 7 days a week
- Referrals
to all specialty services (Medicaid providers only)
- Scheduling
medical appointments as needed
- Accurate
medical records
- Coordination
of all inpatient medical services and care
- Employment
physicals, regular checkups, and sick visits
Services
referred by PCP:
- All
specialty services including OB/GYN
- Lab
testing
- X-ray
services
- Durable
medical equipment
- Audiology
and hearing aids
- All
therapies (including physical and occupational)
- Home
health care nursing services
- Inpatient
services
Services
that do not need a referral:
- Prescriptions
- Dental
care
- Outpatient
mental health/substance abuse services
- Optometry
- Routine
transport for medical services (if eligible)
- Methadone
maintenance services
- Personal
Care Services
- Comprehensive
medical case management
- Family
planning/reproductive health services
- HIV/AIDS
testing and counseling
Frequently
Asked Questions
Who
can enroll?
Individuals
must have current Medicaid status, be age 64 or under,
and be receiving Mental Health and/or Chemical Dependency
Counseling Services in order to enroll
What
services will the member receive through the chose primary
care provider?
The
member is to see the PCP for all regular and sick visits,
in order to obtain referrals, for employment physicals,
and for coordination of all medical care.
What
services can be obtained without referral from the primary
physician?
The
client may use the Medicaid card in the usual way for
all mental health and chemical dependency counseling,
dental care; for optometry and eyeglasses; regular transportation
to medical care (if eligible); prescriptions; personal
care services; family planning and comprehensive Medicaid
case management.
Why
should a client enroll?
Voluntary
enrollment now in PCMP IIA may prevent the client from
being automatically assigned to a different program that
may place limits on inpatient mental health and substance
abuse services. Joining this program will enable the client
to have a personal physician who is responsible for the
coordination of all medical care. Also, Gold Choice has
medically trained case managers to help coordinate services
between the primary physician and the special care provider
and to assist clients in accessing care. The member can
also enjoy the benefits of such programs as the Wellness
Center at the Buffalo Psychiatric Center (BPC).
What
if a client already has a doctor?
Check
the list of Gold Choice physicians. If the client's physician
is not on the list, and the client wants to remain with
that physician, do not enroll. If the client enrolls,
and his/her physician is not part of the program, the
client will lose access to that physician. If the client
clearly wants to change to a different doctor, proceed
with normal enrollment.
What
if a client doesn't already have a doctor?
If
the client wants to enroll, he/she must choose a primary
health care physician from the provider list. Be sure
the client is able to get the location since this is where
nearly all medical care will have to be obtained.
Can
the client change doctors?
If
the client chooses a primary health care provider form
the Gold Choice network, and then wants to change to a
different physician, the client should contact the Gold
Choice member services at 898-5966/1-888-419-1722 to discuss
the transfer, which may be effective in 3-6 weeks.
What
about specialists?
Some
clients may have a particular specialist, but not a primary
physician. After enrollment the client will not be able
to continue with the specialist without a referral from
the primary physician. It's possible the primary provider
will not approve a referral (may judge that specialist
care is unnecessary or may prefer someone else). Client
should understand this before enrollment.
What
about OB/GYN?
An
OB/GYN is also considered a specialist. If the client
has a regular OB/GYN, she must get a referral from her
primary physician before seeing the specialist again.
THIS SHOULD BE REVIEWED VERY CAREFULLY FOR WOMEN OF CHILDBEARING
AGE.
Does
a client need a referral for family planning?
No.
A client may obtain Family Planning services (birth control,
sterilization, and medically necessary abortion) from
any Medicaid provider without a referral. In the same
way, clients have free access to HIV testing and counseling
during a Family Planning encounter. These services may
also be obtained from their primary health care physician.
What
about emergencies?
An
emergency is a medical condition which, if not immediately
treated, may result in death or permanent disability.
When an emergency arises, the client may seek treatment
in any emergency room. Examples of emergencies include
sudden, severe pain that doesn't go away, trouble breathing,
poisoning, and stroke. Clients will not be able to receive
routine, non-emergency care, in an emergency room. The
client should always call his/her primary physician for
advice before going to the emergency room.
What
if a client gets sick at night or on the weekend?
All
primary care physicians have 7 day, 24 hour phone coverage.
The client should contact the primary doctor for medical
device.
Does
joining this program guarantee Medicaid coverage?
No.
The client must still follow all normal procedures to
establish and keep medicaid eligibility.
Will
a client still need a medicaid card?
Yes.
The client will keep the same Medicaid Card to show whenever
getting any medical care along with their Gold Choice
membership card.
What
if a client is already in another managed care program?
It
is, in certain circumstances, possible to transfer from
another managed care program (MCP) to Gold Choice. It
must first be determined if the client is "locked-in"
to the MCP. If not "locked in", a disenrollment
form (from the MCP) and the enrollment package for Gold
Choice must be submitted to Gold Choice for processing.
If the client is "locked-in" to another program,
(s)he will be in that program for 12 months before (s)he
can transfer/enroll into Gold Choice.
What
if a client enrolls in Gold Choice and then doesn't like
the program?
The
client will call the PCMP IIA office at 898-5966 to discuss
the reason. If it can't be resolved, the client will be
instructed to contact the Department of Social Services
for disenrollment procedure.
If
you have any additional questions not covered here, please
feel free to call us at 898-5966 or 1-888-419-1722
Application
Requirements
I.
Medicaid Managed Care Program Enrollment Form
- Please
make sure application is complete including Date of Birth,
Medicaid number, physician and location (please refer
to the Gold Choice "Directory of Primary Care Physicians"
when selecting a Doctor), and all required signatures
(see checklist)
- Once
the application is complete the top copy (white) is for
Gold Choice
- The
client receives the pink copy
- The
agency keeps the yellow copy
II.
Member Attestation Form Checklist
- Please
read all statements with the client
- Must
be signed by both client and counselor
- The
original is to be sent with the application to Gold Choice
III.
Confidentiality Form
- Please
be sure form is signed by both client and counselor
- The
original (white copy) is to be sent with the application
and attestation to Gold Choice
- The
client receives the pink copy
- The
agency keeps the yellow copy
IV.
Disenrollment Form
- Use
for disenrolling from another managed care plan in order
to transfer to Gold Choice
- The
white copy is to be sent with the application package
to Gold Choice.
- The
yellow copy is for the client.
- The
pink copy can be kept in the client's file with the special
care agency.
- Be
sure to fill out completely including CIN#, signature
and date
- Be
sure to choose a reason code from the back of
the form (86A is the most common reason).
Please
keep in mind, following these steps will ensure a timely
processing of applications
Sample
Enrollment Package
----
Enrollment
Checklist
----
Mandate
Information:
- Two
weeks prior to re-certification, the Mandatory Managed
Care Enrollment package is mailed. The Medicaid recipient
is strongly encouraged to choose a managed care program
(MCP) that suits his or her own needs.
- If
the medicaid recipient does not choose a managed care
program at the time of re certification, another package
will be sent and the recipient will have another 60 days
from the time the case is re-certified to respond.
- If
the recipient does not respond to the second enrollment
package within the time given, a managed care program
will be chosen, at random, or auto-assigned, for that
recipient (Gold Choice cannot be auto-assigned)
Also:
- A
recipient ay choose to transfer to another managed care
program within the first ninety (90) days of voluntary
enrollment
To
transfer to Gold Choice:
- If
a client wishes to transfer from another MCP to Gold Choice
within the 90 or 60-day limit, do not contac the MCP for
disenrollment procedure. Gold Choice can provide all the
information necessary for transfer. Please call 898-5966
for assistance.
- If
a client has served the 1-year requirement in another
MCP and now wishes to enroll in Gold Choice please call
us for information on the transfer procedure.
GUARANTEED
ELIGIBILITY
- If
a client has guaranteed eligibility, they are guaranteed
enrollment in any managed care program for the first six
months. This means that a client can lose their Medicaid
and remain in their managed care [program. If you see
this code on the EMEVS machine (ELIG CAP GUARANTEE) you
must be aware that the only services that the client is
eligible for are capitated services. The only services
that will be paid for are Primary Care Services and referrals
from the PCP. They are not eligible for outpatient counseling,
eye care, dental care, methadone maintenance, personal
care and Medicaid case management.
FREQUENTY
ASKED MANDATE QUESTIONS
1. Once
a client has fulfilled the one year loc-in is (s)he re-locked-in
to the managed care program (MCP)?
A:
No. A client can transfer anytime after the lock-in. However
if they do transfer a new lock-in begins
2. If
a client voluntarily enrolled in a MCP before the mandate
is (s)he locked-in to that program at the time of re certification?
A:
No. The client can transfer at any time. Once they do
transfer, they have 30 days to disenroll from the new
MCP after which they will be locked-in
3. Is
there re-certification and/or mandate information given
via e-emevs?
A:
No. Unfortunately at this time there is not. YOu can call
Gold Choice or Department of Social Services to obtain
the information.
4. Are
clients notified when they are no longer locked-in to their
current MCP?
A:
Yes. The Local Department of Social Services is responsible
for providing client with lock-in information
5. After
the client has fulfilled the 12 months of the mandate and
they transfer to another MCP do they same rules apply in
terms of deadlines for transfer?
A:
Yes. Because it is voluntary enrollment in to the new
MCP, the client has 30 days to transfer or disenroll.
EMEVS CODES
| EMEVS
CODES |
PCMP
(PHYSICIAN CASE MANAGEMENT PROGRAMS)
ADDRESS PHONE NUMBER AND CONTACT PERSON |
|
| EK |
FAMILY
MEDICINE PROGRAM -
462 Grider Street, Buffalo, NY 14215 |
898-5966 |
| EN |
ACADEMIC
MEDICINE SERVICES, INC.
462 Grider Street, Buffalo, NY 14215
|
898-5400 |
| E4 |
PCMP
IIA - GOLD CHOICE
Department of Family Medicine
462 Grider Street
Buffalo, New York 14215 |
898-5966 |
| JN |
BUFFALO
PSYCHIATRIC CENTER - RECOVERY PLUS
400 Forest Avenue, BUffalo, New York 14215
Thomas Dodson
|
816-2029
or 816-2020 |
| CODES |
HMO
PLANS/MEDICAID PROGRAM NAME |
|
| HK |
PLUSMED |
875-4444 |
| OZ |
205
Park Club Lane, Buffalo, NY 14221 |
|
| IE |
INDEPENDENT
HEALTH ASSOCIATION / MEDISOURCE
511 Farber Lakes Drive, Williamsville, NY 14221 |
631-3086 |
| C2 |
COMMUNITY
BLUE / COMMUNITY CARE
1901 Main Street, Buffalo, NY 14208 |
884-2800 |
| SP |
FIDELIS
CARE OF NEW YORK
40 John Glenn Drive, Amherst, NY 14228 |
1-800-240-1447 |
Managed
Health Care Office - Department of Social Services - 858-6105
CARE4KIDS
'A
comprehensive medical plan for foster children'
- Foster
children in Erie County will have the opportunity to receive
enhanced medical care as part of the Health Care for Foster
Children Initiative, known at C4K.
- Enrollment
into the Medicaid Health Care Program - CARE4KIDS can
be done at the Child Advocacy Center at 556 Frankly Street,
Buffalo, New York 14202.
- At
this time Gold Choice is currently the managed care entity
that is linked with the CARE4KIDS project as sponsored
through the Erie County Department of Social Services.
Please note that Gold Choice by no means replaces the
relationship with the foster care division or the foster
care case manager. Gold Choice will work with the Foster
Care Child's current Medicaid benefits to provide managed
care services in Erie County. Questions outside of managed
care should be directed to the Child Advocacy Center at
(716) 886-5437 or the Department of Social Services at
(716) 858-6104.
- Upon
enrollment into the CARE4KIDS program a handbook will
be mailed to the child's guardians
Important
Telephone Numbers
---
Consent
Form
---
Disenrollment
Form
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