• Medical Management

  • Medical management involves the coordinated care and case management required to support primary care delivery and reduce the risks associated with chronic conditions.

    Care Management Program

    Care Management promotes Member and PCP engagement in primary care to achieve and sustain optimal wellness of Members in the community. Through evidenced base medicine and a comprehensive approach Affinity will strive to achieve reduction in complications from disease progression. In addition, educate to empower and support self management using health literacy standards, and timely direct the Member to receive holistic/preventive care with qualified health care providers.

    Designating a specialist as PCP
    In September 2010, NYSDOH mandated managed care enrollment for Medicaid beneficiaries with HIV/AIDS. To maximize and improve care coordination, specialists are now encouraged to act as a Member’s primary care physician in individual cases.

    • FAQs: detailed information about the background of this process, who can request the PCP designation; and how the process works
    • Updated credentialing/directory listing for ID/AIDS/HIV providers: AIDS/HIV providers may be listed in the Affinity provider directories as Infectious Disease (or their primary practice specialty) providers, or as AIDS/HIV Specialists. They may also be listed in our directory as “HIV Experienced Providers” if they meet certain criteria.
    • Request to Serve as an Affinity Member’s PCP (mandatory for all providers): fill out request form and fax back to Special Programs
    • Amendment to the agreement for specialty care services between Affinity Health Plan and providers: For contractors who agree to provide primary care services to specific mutually agreed members. This form is intended only for solo providers and providers in small groups who did not submit primary care information to Affinity when they were credentialed or recredentialed.

    Care Coordination

    Care coordination is the process of organizing, integrating, modifying, and documenting the resources necessary to support Primary care.

    Care coordination is the first step towards the assessment and facilitation of the Member’s Care Plan. This coordination of care results in appropriate access to their health plan, assessment of risk for care and proactive arrangement of services. Through communication and coordination among multiple providers, anticipating continuation of care, and identification of condition or psychosocial changes will trigger the need for intensive case management.

    The following programs have been designed with the express purpose of preventing diseases and managing health conditions.

    Mammography Incentive Program

    Affinity Health Plan's Mammography Incentive Program reaches out to our female Members who are over 49 years old and have not had a mammogram during the past two years.

    When we identify a Member who needs a mammogram, one of our Medical Management Coordinators contacts the Member by phone or mail. The Coordinator verifies whether or not the Member has had a mammogram. If the member has not had one, the Coordinator then helps the Member schedule the mammogram appointment at one of our participating radiology facilities.

    After the Member has her mammogram, Affinity sends the Member a $25 Visa Gift Card as a reward for making the effort to have this critical screening exam. The Member may use the Visa card at any participating store or with any merchant.

    Healthy Beginnings Program

    The Healthy Beginnings program provides care management services for pregnant Members. Members can talk to a nurse any time during and after they give birth to get answers to questions on their pregnancy.

    A report summarizing each completed pregnancy assessment will be sent to the provider. In addition, should a nurse identify any urgent needs, your office will be contacted by phone and your patient advised to seek appropriate medical attention.

    Members who keep their prenatal and postpartum appointments can receive up to $50 in gift cards as a reward. The Member may use the gift cards at any participating store or with any merchant, but it cannot be used for the purchase of cigarettes or alcohol. Providers will need to sign a validation form attesting to their prenatal and postpartum visits for the members to receive the gift cards.

    If you have questions about the program or to refer a member to the program, please call Alere at 844.238.2229 Monday through Friday 8:00 am – 12:00 am, Saturday 9:00 am – 9:00 pm.

    Primary Care

    DOH General Standards

    • All Medicaid patients shall be offered the opportunity to select or change their own primary care clinician (PCC).
    • Primary care physicians (MD/DO) must be Board Certified or Board Eligible in their area of specialty, or have completed an accredited residency program in Internal Medicine, Family Practice, Pediatrics, or Obstetrics/Gynecology, or meet the standards for residents training in those fields as described in Additional Standards for Article 28 Facilities with Training Programs in Internal Medicine, Pediatrics, and/or Family Practice".
    • Primary care nurse practitioners must be certified in a primary care specialty.
    • Physicians must either have admitting privileges at one or more hospitals or have an arrangement for hospital coverage (hospitalist is acceptable) provided there is a mechanism to share patient information for continuity and follow up care.
    • Clinicians billing for primary care services shall provide health counseling, education and advice; conduct baseline and periodic health examinations with content consistent with EPSDT/CTHP requirements and professional guidelines including the US Preventive Services Task Force; diagnose and treat conditions not requiring services of another specialist; arrange inpatient care, consultations with specialists, laboratory and radiologic services when medically necessary; coordinate findings and recommendations of specialists and diagnostic results; interpret findings to the patient and patient's family as appropriate and allowable under confidentiality rules; maintain a current medical record for the patient.
    • Practices must provide 24 hour/7 day week coverage (after hours and weekend/vacation number to call that leads to a person or message that can be returned within one half hour).
    • Practices must: 1) identify to patients the name of the person who is their primary care clinician; 2) promote an ongoing relationship with an identified primary care clinician who will provide continuous and comprehensive care; 3) make use of a practice care team when necessary to assure continuity.
    • Practices must monitor appointment availability and time slots to ensure timely access to routine or planned care as well as expedited or same day care for immediate health care needs; allow sufficient time for physical examinations and treatments; allow sufficient time for patient education.
    • Practices must provide reminders/call backs to patients needing continued or follow-up services for primary and secondary prevention.
    • Practices must provide self-management support (education, care plans, etc.), directly or through use of ancillary staff for individuals with chronic conditions including but not limited to diabetes and asthma.
    • Practices must have the means to incorporate evidence based guidelines into practice for periodicity/prevention schedules, and guidelines for at least one chronic disease of high prevalence.

    Special Needs Plan Model of Care (SNP MOC)

    Coordination of care is an integral component of the partnership between providers and Affinity Health Plan toward improving our members’ health and wellness. Affinity Health Plan’s Model of Care training is made available to all our providers. To schedule an appointment for training please contact your provider relations representative at 718.794.5952.