Eligibility: All Dual-SNP and Medicare members, Tier 1 and 2 HARP and (Supplemental Security Income) SSI Medicaid members, high-risk Qualified Health Plans (QHP) members

Benefits: Care Manager works with member for up to 30 days after hospital discharge to reduce likelihood of hospital readmission by ensuring PCP follow-up, medication reconciliation, and education.

Eligibility: All Dual-SNP and Medicare members

Benefits: For all Mental Health and Substance Use Disorder (MH/SUD) admissions, a designated Transition of Care (TOC) Care Manager and TOC Associate work collaboratively toward reducing hospital readmissions and ensuring aftercare follow-up. TOC team follows case during admission and up to 30 days post discharge. Interventions include, but are not limited to:

• Discharge plan follow-up
• Appointment scheduling
• Appointment reminders
• Transportation assistance
• Assistance obtaining medication
• Linkage to community social services
• Education related to MH/SUD conditions

Eligibility: Medicaid, HARP, Qualified Health Plans (QHP), Essential Plans

Benefits: Telephonic case management for up to 30 days post discharge. This includes, but is not limited to:

• Assistance with discharge plan follow-up
• Appointment scheduling
• Transportation
• Assistance obtaining medication
• Linkage to community social services
• Member education
• Member self-advocacy

Eligibility: All active Dual-SNP members

Benefits: Assist member with obtaining PCP/specialist. Program also helps to:

• Promote preventive care
• Coordinate care between providers
• Locate community resources
• Arrange medical supplies/durable medical equipment (DME)
• Recover after hospital stay
• Provide member education

Including: Sickle Cell / Hemophilia HIV High Risk OB/NICU OncologyBreast Cancer Transplant Complex Conditions General Disease Management

Eligibility: All LOBs with the exception of Dual members

Benefits: Comprehensive telephonic case management program outreach performed by registered nurses. Multiple specialties within the program to help support the most vulnerable and acute members. Receipt of referrals from many sources, including directly from members themselves and their providers. Goal is to connect with our members, encourage them to engage with the case manager to drive better health outcomes. 

Case managers work with the members to complete a comprehensive risk assessment. Helps to identify gaps in care and potential barriers such as low health literacy and social determinants of health (SDOH). Case manager and member work to create an individualized care plan to address gaps and barriers. One goal is to assist the member in developing a self-management plan to help them take charge of their health needs. 

Ongoing member engagement is largely dictated by the member’s level of engagement and how fast care plan goals are met. Members can be admitted and discharged from case management based on their needs and with significant changes.

Eligibility: Members are referred internally from medical case management programs

Benefits: Assist members with social determinants of health (SDoH) barriers, including financial and legal issues, Home Energy Assistance Program (HEAP), food banks, housing issues, vocational training, and other community resources.

Eligibility: Medicaid, Medicaid SSI, Child Health Plus (CHP), Health and Recovery Plan (HARP), Qualified Health Plans (QHP), Essential Plans

Benefits: Telephonic outreach to members with frequent ER utilization for non-emergent reasons. Goal is to help reduce unnecessary ER utilization by identifying/removing barriers to care, promoting PCP linkage, and urgent care usage. Members may also be linked with a case manager.

Eligibility: Medicaid members 21 and older identified by NYS as eligible to join a Health and Recovery Plan (HARP)

Benefits: Provides member all Medicaid Managed Care benefits for HARP members 21+. Services include, but are not limited to:

• Complete member risk assessment and person-centered care planning
• Coordinate for physical health and behavioral health needs
• Evaluate and assist with Health Home referrals
• Engage with providers, natural supports, and community supports to collaborate on care
• Follow up on transitions of care
• Re-engage and refer members to care for behavioral health, physical health conditions, and SDoH needs
• Educate and refer to Home and Community Based and CORE Services. All HARP members are managed as long as the member remains with the HARP plan.

Eligibility: Members in any LOB (excluding HARP) who meet BH criteria and agree to program participation

Benefits: Provide short-term, telephonic case management services. BH also has a designated inpatient and outpatient utilization management team. Services include, but are not limited to:

• Develop and monitor person-centered care plans
• Coordinate member’s care
• Link members to community support resources and Health Home Case Management services 

Eligibility: Medicaid members under the age of 21

Benefits: Primary focus on gaps in care for Children’s Home and Communicated Based Services (HCBS) and Children and Family Treatment Support and Services (CFTSS) under the age of 21. Services include, but are not limited to:

• Ensuring linkages to HCBS and/or CFTSS
• Person Centered Care Planning
• Coordination of care for physical and behavioral health needs
• Engaging natural supports into care process
• Connection to concrete services, such as benefits and community resources
• Plan of Care oversight for members enrolled with Health Homes/Care Management Agencies and Children and Youth Evaluation Service (C-YES).

Eligibility: Members under 21 enrolled in Voluntary Foster Care Agencies or Local Department of Social Services (LDSS) Foster Care.

Benefits: Linkages to mandatory assessments and screenings; initial health screening followed by care planning led by Child Advocate, Nurse CM or BH CM as appropriate; discharge planning; transition of care planning for members entering or leaving foster care; linkage to health home services; coordination of care.

Eligibility: Members under the age of 21

Benefits: Provides comprehensive telephonic case management for members from birth to 21 years of age. Multiple specialties within the program are designed to help support the most vulnerable and acute members, such as pediatric transplant, HIV, neonatal home discharge, and all post-discharge rehabilitation stays. 

All members are assigned a Registered Nurse Case Manager who provides person centered care. Referrals are made from internal and external sources. The Nurse Case Managers provides service utilizing an interdisciplinary team approach to ensure the member’s needs and services are being completely met. 

The focus is on pediatric members who need DME, PDN, CDPAS, and Community Services. The goal is to collaborate with Health Home Care Managers to ensure connectivity to all available Community based services to guarantee there are no gaps in care.

Eligibility: All Medicaid, Medicaid SSI, and Qualified Health Plans (QHP) members

Benefits: Provides personalized remote patient engagement and care coordination communication system primarily via text messaging or telephonic outreach as necessary. Services include, but are not limited to:

• Promote preventive care
• Coordinate care between providers
• Locate community resources
• Arrange medical supplies/durable medical equipment (DME)
• Assist with recovery after hospital stay
• Decrease ER utilization
• Member education

Members are linked to a case manager for an average of 90 days or longer if warranted. Members also receive educational or reminder concierge messages directly from GoMo.

Eligibility: For people who need long term care services and help to live independently in their own homes and communities. The member must have or be eligible for New York State Medicaid, be 18 years of age or older, and have been assessed by a nurse as eligible for the required level of care. As a Fidelis Care at Home member, they will work with their physician and Nurse Care Manager on a plan of care that best meets their needs.

Benefits: A wide range of services are available to meet individual circumstances. Services include, but are not limited to:

Eligibility: The PCS benefit is available for Managed Medicaid members who are in need of personal care services. Members must have a stable medical condition that is not expected to exhibit sudden deterioration or improvement and does not require frequent medical or nursing judgement to determine changes in the patient’s plan of care.

Benefits: Personal Care Services, including utilization of the Consumer Direct Personal Assistance Program if requested; Level 1 care, which includes housekeeping, shopping and meal preparation, and Personal Emergency Response Systems.