Medicaid and Child Health Plus
New York’s managed care plans have been a strong partner with the state for nearly 30 years. Together, the state and plans have worked to expand coverage and improve quality of care for lower income and underserved populations. More than five million New Yorkers are enrolled in managed care plans through a variety of government-sponsored programs such as Medicaid Managed Care, Child Health Plus and New York’s Essential Plan. The following member* stories offer real examples about how plans support the health care needs of theses members.
* Some names have been changed to protect member privacy
Yvette
After years of dealing with arthritis and fibromyalgia, Yvette tore her ACL and needed surgery, but she didn’t have insurance.
While at the hospital, she was referred to Fidelis Care. The next day, a Fidelis Care representative came to her house and helped to get her enrolled. Learning that her three children also needed coverage, the plan representative made sure they would be covered as well. Yvette’s case manager, Harpreet, says the plan’s dedicated team knows each member’s needs and priorities, adding “you feel like you have someone who knows you very well.” Yvette says, “I don’t think I’d have the quality of life I have now if I had different insurance.”
Chelyssa
During her first pregnancy, Chelyssa experienced dangerously high blood pressure and a premature delivery. Her doctors told her if she got pregnant again, she would need specialized care.
When she found out she was expecting again, Chelyssa was nervous and anxious that it would be a repeat of her first pregnancy. Thankfully, her doctor recommended Fidelis Care’s BabyCare program that provides individualized care designed to support high risk mothers in ways that work for them. From the start of her pregnancy, Chelyssa worked with her BabyCare case manager, Dawn, who helped relieve Chelyssa’s anxiety and build her confidence. “Dawn treated me like a friend,” says Chelyssa. “She kept me grounded.”
Thanks to Dawn and the BabyCare program, Chelyssa’s second son was a healthy, happy and full term baby.
Adult Health NP House Calls
Dr. Willa Arnet started Adult Health NP House Calls to bring care directly to people when they are unable to leave home. Focusing on Medicaid beneficiaries who have not recently used the health system, she provides in-home visits with a comprehensive physical exam.
Independent Health identified a member who was a new mother who had not been accessing health care services since giving birth in the hospital and connected her with Dr. Arnet. She told Dr. Arnet that during her delivery, the medical professionals had not been responsive to her concerns and needs, including not providing sufficient numbing agents for a cesarean — even after she had expressed acute discomfort. Dr. Arnet’s responsiveness and her concern for the mom and her baby helped restore some of the mom’s trust in system. Thanks to Dr. Arnet and Adult Health NP House Calls, this new mother and her baby are now receiving the care they need to help ensure they both have a healthy future.
Manny
Manny is one of the more than 390,000 children in New York who have asthma. Although there is no cure for asthma, proper care and treatment can help control it and prevent attacks. Anthem Blue Cross and Blue Shield’s “Improving Asthma” program, a partnership with the New York City Department of Health and Mental Hygiene, is working to address childhood asthma and improve treatment outcomes.
Because homes, can be a major source of asthma triggers which can make asthma worse — particularly in urban settings and where pest management can be a challenge — one focus of the program is to help families reduce these triggers.
In Manny’s case, Anthem was notified after the seven-year-old went to an ER because of his asthma. Community health workers were dispatched to the home where Manny and his single mother and six siblings were living in extreme inhabitable conditions and, through the program, the plan was able to connect with the family’s social worker, have a cleaning company deep clean the home, and reduce asthma triggers in the home. The plan continues to follow up, making sure Manny remains adherent with his asthma medication, and is also working with the mother on nutrition education since Manny was also diagnosed with diabetes, and connecting the family with resources in the community.
Paul
In 2021, Paul, a Fidelis Care Medicaid member, was homeless, coping with diabetes and struggling with food insecurity. The Fidelis Care SOAR (SSI Outreach, Access, and Recovery) program was there to help with Community Relations Specialists who engage with the most vulnerable populations, providing support and assistance.
Carla, a CRS in Erie County, began working with Paul, helping him schedule appointments with a primary care physician and an endocrinologist to get his diabetes under control. He has since received an implanted glucose monitor, which has helped him better manage his glucose levels and reduce hospital visits.
“I dedicate myself to these members and am their biggest advocate because they are human beings and deserve the best chance to live a healthy life,” Carla said. “Too many people have given up on Paul in his life. I won’t walk away. It’s so rewarding to see Paul with a better life in his future.”
Today, Paul is no longer homeless — living in an apartment — is receiving food stamps and has access to the local food bank near his new home.
Tiana
Tiana, a 26-year-old Fidelis Care Medicaid member, was not working after having her second child and needed financial assistance to help pay for food, rent, and utility bills. When Maureen, a licensed master social worker, learned that, she worked with Tiana to help her apply for and receive assistance through WIC, HEAP, and SNAP. That help enabled Tiana to provide food and formula for her 2 children and pay her heating bill.
Maureen also encouraged the member to have her landlord complete the necessary paperwork for Samaritan Center, which provides emergency financial assistance to low income and vulnerable people, which qualified her for rental assistance.
After Tiana also shared how challenging it was to return to work because she could not afford daycare, Maureen helped Tiana apply for and receive a daycare subsidy available for low income parents needing to return to work or school.
Maureen shared her thoughts on working with Tiana, saying, “Being able to tell this member — a mom of two with a newborn — that she could go back to work knowing her kids would be taken care of was an amazing feeling. I could hear the relief in her voice.”
Mickey
At 85, Mickey L., a former jazz drummer, continues to give back to his community, volunteering at the youth music program of a local school three times a week. However, because he lives alone in a senior apartment complex and has multiple chronic conditions, accessing care is often a burden.
After enrolling in MVP’s Dual Special Needs Plan (D-SNP), Mickey was contacted by the MVP care team who told him that one benefit of his plan was bringing a multidisciplinary group of experts together, to work with him to ensure he has what he needs to manage his health. The team, including a nurse care manager, licensed clinical social worker, community health worker, pharmacist and the Chief Clinical Officer, reviewed Mickey’s clinical status, medications, health care utilization and social determinants, and created a care plan to address each of his needs. They also made sure he had transportation to future appointments, replaced his lost over the counter drug card and did a thorough review of his medications. One of Mickey’s biggest concerns was about his housing — how would he focus on his health, on his well-being and his community if he did not have a home? Once again the MVP team worked together to formulate a plan to support Mickey. Working with his care team on a regular basis, Mickey knows that no matter what he faces in the future, they will be there to support him.
Jillian
When Jillian M.’s three-year-old daughter got sick in September 2021, she thought it was just a cold. The little girl, Nala, had tested positive for COVID-19 five weeks prior, but experienced no symptoms at the time. Nala is covered by Child Health Plus (CHP), and her care is overseen by CDPHP, one of New York’s managed care health plans.
After several weeks, when Nala stopped eating and drinking, was extremely fatigued and had a fever of 104, Jillian took her daughter to the emergency room where she was admitted to the hospital’s intensive care unit and diagnosed with multisystem inflammatory syndrome in children, or MIS-C, a condition some children develop after being diagnosed with coronavirus. Doctors quickly got the girl’s symptoms under control, and after being transferred to the pediatric unit, CDPHP’s nurse care manager stepped in with its Hospital to Home program designed to keep patients and their loved ones informed during and after a hospital stay. A team helps connect patients with resources they may not be aware of, schedules follow up visits when a patient is ready to be discharged, and oftentimes, just lends an ear to those in need. Through this interaction, Jillian opened up, explaining that she had missed several weeks of work while trying to care for her daughter, falling behind on rent and unsure how she would put food on the table or heat her home. The CDPHP nurse manager and her team sprang into action, connecting Jillian with resources she needed to get back on her feet, helping her apply for heating assistance and connecting her with a local food pantry. They also put her in touch with Building on Love, a local organization that provides emergency financial assistance to families facing medical emergencies.
“What started as a horrible situation turned out to be such a blessing,” said Jillian. “CDPHP was an advocate for me and my family. It didn’t matter if I need help financially or emotionally, they were there for me. I always felt like I was talking to a friend.”
James
James P.*, a 63-year-old member with behavioral health needs, came to the attention of the Anthem Blue Cross and Blue Shield case management team following a behavioral health hospitalization.
Because of his circumstances – he was homeless and had been living in a hotel that he was paying for with limited funds – James had stopped accessing services, leading to a deterioration of his conditions and ultimately requiring him to be hospitalized. Fortunately, Anthem Blue Cross and Blue Shield’s HARP care management team was able to successfully engage him, acting quickly to refer James to an array of resources connecting him with a community case management agency and home and community-based services. Under the leadership of the HARP care management and utilization management team, community service providers are currently working to assist James in applying for long term housing along with securing employment.
Will
Will S*. is an Anthem Blue Cross and Blue Shield member diagnosed with severe asthma, requiring regular albuterol treatments. He also had transportation issues because his parents are very sick and could not take him to see his providers regularly. As a result, he ended up in the emergency room twice in 2020, and ended up being admitted for asthma related symptoms.
The admissions were entirely preventable had Will and his mother reached out to his primary care provider and sought care earlier. Another contributing factor was harsh cleaning chemicals being used in the home that were a trigger for him at times. Anthem deployed a community health worker to meet with the family. The community health worker educated the mother on ER usage and asthma diagnosis, and Will on his health conditions, helping him become more knowledgeable about his triggers so he can work to avoid them. The community health worker also worked with the family to get transportation to appointments and, as a result, Will has seen his PCP regularly throughout the year as well as his pulmonologist. The family has also switched to less harsh, more environmentally safe cleaning products. All these steps helped and Will did not have a single ER visit in 2021.
Maria
Maria C.*, a 27-year-old Spanish-speaking member, was an expectant first-time mother, working part-time at a local restaurant. She was experiencing feelings of stress and occasional hopelessness, especially since her baby’s father and her immediate family resided outside of the U.S. At 21 weeks into her pregnancy, Maria met with the Anthem Blue Cross and Blue Shield case management team, forging a connection that would change her and her baby’s life.
Case management in the OB program referred her to a suite of different services and supports to help her and her baby. The array of services included Anthem’s Internal Behavioral Health team (who connected her with a Spanish-speaking psychotherapist), the Special Supplemental Nutrition Program for Women, Infants, and Children (commonly known as WIC), the Nurse Family-Partnership program and doula services. The plan also sponsored a Spanish-speaking virtual baby shower for Maria and provided a breast pump.
With the help of these various supports, she delivered a healthy full-term child. Maria also remained closely connected to the doula program, her NFP Nurse and psychotherapist after the birth of her baby and obstetrical case management services continued through the postpartum period as she transitioned into her role as a new mother. As a result, Maria remains healthy, and her baby is meeting all expected milestones and continues to thrive!
Marie
Before connecting with the Anthem Blue Cross and Blue Shield case management team, Marie P.*, 63-years old, had experienced homelessness for almost four years. Marie has a host of mental and physical health complications, including major depressive disorder, opioid related disorders, generalized anxiety disorder, PTSD and borderline personality disorder. She also suffers from high blood pressure, chronic ischemic heart disease, High LDL and type 2 diabetes.
In 2020, she was evicted from an assisted living facility for nonpayment of rent and attempted suicide. Admitted to Harlem Hospital, she was connected to the Anthem case management team, and it was during this time that she got support and resources that eventually led to meaningful housing stability she hadn’t experienced in years. Upon their meeting, the Anthem case management team leaped into action and case managers introduced her to peer support services and helped to successfully coordinate an Assertive Community Treatment plan, utilizing a team approach designed to provide comprehensive, community-based psychiatric treatment and rehabilitation. The Anthem case management team remained in close contact with Marie throughout her time in and out of the hospital. This relationship has been instrumental in keeping her motivated to apply for housing and to stay engaged with her ACT team to extend her time out of the hospital while receiving crisis residential services and attending housing interviews. There has been tremendous internal collaboration between inpatient and outpatient utilization management, case management and the HARP medical director that has resulted in helping her to get vital documents required to complete her housing application. Because of the tireless efforts and dedication of all involved team members, Marie was able to move into permanent housing through Concern for Independent Living, a non-profit agency committed to helping low income and deniable persons achieve their goals of greater independence.
Jane
Jane L. is a 63-year-old English speaking female MetroPlusHealth Medicaid member who also has a history of type 2 Diabetes, hypertension and high cholesterol as well as tongue cancer. When a MetroPlusHealth care manager connected with Jane to support her transition back to her home after being discharged from the hospital, the care manager realized Jane did not have reliable transportation to appointments.
The plan worked with Jane to make sure she had transportation to medical appointments. Because her diabetes was poorly managed, the care manager also recognized Jane needed assistance to address her food insecurity as well as poor access to nutritious foods, and connected her to supplemental nutrition assistance program (SNAP) benefits and food pantries in the immediate area. The care manager also learned that a number of the member’s radiation oncology appointments had been canceled. Unfortunately, the reasons for the cancellations had not been clearly communicated to Jane, resulting in her feeling anxious and abandoned by her clinical team. The care manager was able to facilitate improved communication with the team, allowing Jane to resume her scheduled radiation treatments the next day. Further, the care manager educated Jane on the importance of attending treatment consistently despite painful side effects.
As a result of the advocacy on her behalf, Jane’s care is coordinated and she’s able to access helpful benefits. Best of all, Jane reports her diabetes has improved, her pain is now controlled, and she is stronger and enjoying life again!
The Shelby Family
The five members of the Shelby family, all MetroPlusHealth Medicaid members, have unfortunately experienced longstanding homelessness, moving in and out of Department of Homeless Services shelters since 2017.
The mother, at 25 years old, had recently had her third child after a difficult pregnancy, complicated by anemia and respiratory disease. She had also been struggling with an anxiety disorder, which detracted from her ability to manage her family’s needs.
The family first came to the attention of the MetroPlusHealth housing task force after being notified by DHS. When staff reached the mother, they determined the family was eligible for the Emergency Housing Voucher program due to her previous medical conditions. MetroPlusHealth was able to assist her with the application, resulting in her being housed in a 3-bedroom apartment in the Bronx with her partner and three children in September 2022. The family is happy to have their own private space for the first time in 5 years. Taskforce staff are now helping the family with key next steps towards health and wellness, such as coordinating connections to medical providers, finding behavioral health services for the mother to address her anxiety, and identifying community-based resources for assistance with school/child care.
Veronique
When Veronique B. was admitted to the hospital her blood glucose and A1C levels were extremely high. The 47 year old, a member of Molina Healthcare of NY, also weighed 286 pounds at the time and was diagnosed as diabetic.
Placed on multiple medications preventatively, including insulin, metformin, and hypertensives, Veronique said she was “scared to death.” She admitted that she went about her life but did not really care much about her health….until this happened. Working with Molina’s case management team, after two months, Veronique’s A1C dropped significantly, her blood sugars are now in normal range and she’s lost 31 pounds as well! Thanks to timely intervention from her plan’s team and Veronique’s commitment and hard work, she is now only taking one medication and is no longer considered diabetic.
