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An Introduction to HIV Special Needs Plans
An HIV Special Needs Plan, or HIV SNP (you can say it like "HIV snip"), is
a new kind of Medicaid health plan for people with HIV/AIDS and their children.
Right now, people with HIV don't have to join an HIV SNP, but they can if they
wish. If they don't want to join an HIV SNP, they can remain in traditional
Medicaid or pick a mainstream Medicaid health plan. Adults without HIV cannot
join an HIV SNP.
What are Medicaid health plans?
Medicaid is a health insurance program for many people with
low incomes. When it started, Medicaid was a fee-for-service (FFS)
program. This means that the government paid providers like doctors,
clinics, and hospitals, for each of the services they gave to people with Medicaid.
Recently, managed
care principles have been increasingly applied to the Medicaid program.
With managed care, the government pays a health plan a fixed amount for each Medicaid
beneficiary who is a member.
The Medicaid health plan then gives most of the member's care. This change
was made to save money and to give better care. Medicaid health plans that serve
anyone, with or without HIV, are sometimes called
mainstream Medicaid health plans.
In New York State, Medicaid managed care is becoming a mandatory program. People
with Medicaid in some zip codes have to pick a Medicaid health plan. People who have
HIV are exempt from mandatory managed care for now. This means they
can join a plan or decide to stay in traditional fee-for-service Medicaid.
What are HIV SNPs?
HIV SNPs are a new type of Medicaid health plan. They are for people
with HIV and their children. These health plans link medical and social services to meet
the special needs of people with HIV.
How are traditional Medicaid, mainstream Medicaid health plans,
and HIV SNPs different?
There are some similarities and several important differences.
- 1. Benefits
- People in HIV SNPs and Medicaid health 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.
- 2. Case management
- An HIV SNP links medical and social services to meet the special needs of
people with HIV and their children. So, HIV SNP enrollees have case
managers who help coordinate all of the medical and social services
that members get.
- 3. Providers
- In traditional Medicaid, people can see any provider who takes Medicaid. In
an HIV SNP, enrollees can usually go only 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 providers
are HIV specialists, which means they have 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 health plans and HIV SNPs usually need a
referral from their primary care providers and can only see
specialists in the plan's network.
|
| Traditional Medicaid |
Mainstream Medicaid
health plans |
Medicaid HIV SNPs |
| Benefits |
Standard package |
Same, but some are given inside and some outside the plan |
Same, but some are given inside and some outside the plan |
| Coordination of benefits |
People coordinate their own benefits |
PCPs coordinate enrollees' medical care |
PCPs coordinate enrollees' medical care and case managers
coordinate clinical and social services |
| Providers |
People can see any provider who takes Medicaid |
People can usually see only providers within their health
plan's network |
People can usually see only providers within their health
plan's network |
| Primary Care Providers (PCPs) |
No primary care providers |
Primary care providers don't have to be HIV specialists |
Primary care providers are HIV specialists |
| Specialists |
People can see any specialist who takes Medicaid |
People usually need a referral from their PCP to see a specialist,
and can only see specialists in the plan's network |
People usually need a referral from their PCP to see a specialist,
and can only see specialists in the plan's network |
Does my client have to join an HIV SNP?
No. HIV SNPs are voluntary now. This means that
people with HIV who have Medicaid can either stay in traditional
Medicaid, pick a mainstream Medicaid health plan, or pick an HIV
SNP. They won't lose their Medicaid benefits if they don't join
an HIV SNP.
Sometime in the next few years, HIV SNPs may become mandatory. This means that
people with HIV who get Medicaid may have to pick an HIV SNP or a mainstream Medicaid
health plan and won't be able to stay in traditional Medicaid. But some groups of
people, like homeless people, will still be able to stay in traditional Medicaid
if they want to.
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