Medicaid Managed Care Teleconf- For SPAN- 4-1-09%5B1%5D

7/28/2019 Medicaid Managed Care Teleconf- For SPAN- 4-1-09%5B1%5D

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Family Voices of New Jerseycopyright 2009 1

Health Care Advocacy in the

Managed Care EnvironmentMedically Necessary Services; Primary Care Providers;Specialty Care; Covered Services; Costs; Choosing HealthCoverage and Providers; Prescription Drugs

Presented by Beverly Roberts, Arc of New Jersey,

Director, Mainstreaming Medical Care Project

Hosted by Family Voices-NJ/

Family-to-Family Health Information Resource Center of theStatewide Parent Advocacy Network

April 1, 2009


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Medicaid Managed Care

workshop objectives What services are covered Useful terminology

Selecting a plan or a provider Working with your providers Advocating for your child Dispute resolution Resources for support and informationFind highlightedwords in Important Terms handout, Fact sheet # 7,

at http://www.spannj.org/familywrap/medicaid_fact_sheets.htm.
http://www.spannj.org/familywrap/medicaid_fact_sheets.htmhttp://www.spannj.org/familywrap/medicaid_fact_sheets.htmhttp://www.spannj.org/familywrap/medicaid_fact_sheets.htmhttp://www.spannj.org/familywrap/medicaid_fact_sheets.htmhttp://www.spannj.org/familywrap/medicaid_fact_sheets.htm


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Managed care When it works well, Medicaid

managed care can provide a

comprehensive approach to providingand paying for high-quality medically-necessary health care services - from routine to emergency - within a coordinated system -

in a cost-effective manner


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Health Maintenance

Organizations (HMOs) The health plans that provide the Benefits

Package for the Medicaid managed care system

in New Jersey AmeriChoice Amerigroup Community Care Horizon NJ Health Health Net University Health Plans


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Medicaid managed care and

NJ FamilyCare The original name of the program was

Medicaid managed care.

The Medicaid office now calls the programNJ FamilyCare.

NJ FamilyCare includes the Medicaidpopulation as well as higher incomeenrollees. In these slides, the termMedicaid managed care or Medicaid HMOswill be used.


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The Basics of HMOs Medicaid HMOs provide coverage for

enrollees in a geographical area for a

prepaid, fixed capitation rate. The fee is paid by Medicaid no cost

to the enrollees as long as they see

providers in the HMOs network.


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Hallmarks of Managed Care

Using specific providers Not relying on the emergency room

for primary care services Authorizing of specialty care and

referrals

from The Boggs Center University Center of Excellence


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Characteristics of Medicaid

managed care Health Benefits Coordinator (HBC) handles enrollment into HMO HMO ID card HMO Member handbook HMO Primary Care Provider (PCP) HMO Care Manager HMO Individual Health Care Plan (IHCP) HMO Provider Network (provider directory) Referral Prior authorization Emergency vs. urgent vs. routine care


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Covered Services HMO benefits package

Primary & specialty care

Preventive health care & counseling Health promotion EPSDT (Early Periodic Screening, Diagnosis, & Treatment) Emergency Medical care Inpatient hospital care (acute, rehab, specialty)

Outpatient hospital Laboratory Radiology Audiology


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Inpatient rehabilitation

Podiatrist Chiropractor

Optometrist

Optical appliances

Hearing aid services

Home health (with limits)

Hospice

Durable Medical equipment & medical supplies


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Prosthetics & orthotics (including shoes)

Dental Organ Transplants

Post-acute care

Mental health/substance abuse for DDD clients (non-DDDclients continue to receive mental health services on a fee-

for-service basis as they did in the past)


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Includes mental health & substance abuseservices for DDD clients (these servicesare carved out for everyone else)

Include some transportation

HMOs may offer participants additionalservices beyond those Medicaid entitlesthem to


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Services that are Carved Out HMO carve out services, which arestill paid for by Medicaid fee-for-

service: PT, OT, and Speech therapy Some transportation Mental health & substance abuse services for

non-DDD clients Medication for special needs enrollees (in aged,

blind and disabled category) Home health care


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Care Management

Very Important Service! The HMO will assign a Care Manager. ALL children

with special healthcare needs in NJ MedicaidManaged Care are entitled to a Care Manager!

Usually a nurse or social worker The Care manager helps coordinate your childs

care S/he is the first person to contact with a question,

or concern with your childs health coverage Request a care manager if not automaticallyassigned to one Member service staff are very different from

care managers.


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Costs Medicaid entitles beneficiaries to free health

care. Always bring your HMO ID card to all

visits. Also bring the plastic Medicaid Identification

card

Enrollees who follow correct HMO proceduresshould never receive a bill.

(If you dont follow procedures you may be heldliable for bills.)


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Balance Billing Is

Not Permitted Medicaid enrollees who follow the

rules of the HMO should never

receive a bill. However, sometimes bills are sent in

error by a hospital or doctor. If this

happens, contact HMO care managerand ask her to fix the problem. Dontignore any bills that you receive!


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Using Medicaid Managed Care Call the HBC to enroll in an HMO 800-701-0710 Read your HMO member handbook

Select & work with your PCP (Primary care provider) Get referrals for other services Work with your care manager Use network providers

Use emergency rooms only for emergencies(prudent layperson decision) If you think your child needs emergency care, go to

the ER!


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Exemption from Medicaid

managed care The exemption process is now hassle-free!

If your childs health care needs are beingmet from Medicaid fee-for-service, youcan request an exemption.

Call the Health Benefits Coordinator at 1-

800-701-0710 to request. All requests are honored.


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Choosing a Medicaid HMO plan Which Medicaid HMO is best for your child?

Are the doctors you want for your child in this HMO? Yourchilds hospital?

Does the HMO provide services in convenient locations notjust PCP, but also laboratories for blood work, medical

equipment, specialists? Are your childs specialty clinics in the network? If not, will

the HMO be willing to refer your child outside the network tothese specialty clinics?

What dental services are provided? Are they accessible?

Are your childs current durable medical equipment suppliers inthe HMOs network? If not, how will you access them? Do the providers speak your language or have interpreters?


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Choosing an HMO Which Medicaid HMO is best for your child?

Which HMO provider network(s) are your childsmost important current providers in? Ask your providers or the HBC.

Some of your providers may be able to join the providernetwork for the HMO that looks best to you. Ask theHMOs member services.

Choose the plan that has your most important currentproviders or that meets most of your requirements.

Remember that you can switch to a different MedicaidHMO if you need to. There is no lock in. If necessary, you can request an exemption and return

to regular Medicaid.


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Choosingproviders

Who is the best PCP for your child? Does the provider have experience working withfamilies of children with special health care needs?

Has the provider worked with children with yourchilds special needs before?

Who will see you when he/shes not available? Is the office close to your home? Convenient

hours? Are the office & exam rooms accessible to you? Does this provider speak your language or sign? Does the provider offer access to the specialty

services your child needs? What hospitals is the provider affiliated with?.


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Hospitals and Managed Care Keep in mind that the HMO network

includes not only doctors but also

hospitals, labs, durable medicalequipment providers, etc.


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Once youve chosen Read your Member Handbook carefully!

Identify important people and phone#s and post them by your phone

Be sure you learn how to reach helpafter hours!

Keep records of all provider contacts incase misunderstandings arise


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After youve chosen,

you may still change HMOs if you have major problems.

Call the HBC to process changes(1-800-701-0710)

Changes take time between 14 and 45 days ormore PCPs if you are not satisfied with your first

selection. Call HMO member services, or talk to your care

manager for information on selecting a new PCP You can also disenroll from the HMO and return to

Medicaid fee-for service by calling the HBC


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Medically Necessary Services

are services required to: diagnose or prevent an illness, injury or

condition

treat an illness, injury, or condition keep condition from getting worse

lessen pain or severity of condition

help improve condition

restore lost skills (rehabilitation)


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Medically Necessary:

requirements for children The service is appropriate for the

age & health status of the child;

the service will aid overall physical &mental growth & development; and/or

the service will assist in achieving or

maintaining functional capacity.


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Dealing with Emergencies If you, as a prudent layperson, decide

that your child has an emergency medical

condition, the HMO pays for the hospitalEmergency Room treatment withoutrequiring a referral or pre-approval.

Call 911 or go to nearest emergency room DONT use emergency room for routine

care!


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Dealing with Urgent Care Call HMO 24-hour toll-free number ifyour child needs urgent care (attention

within 24 hours but not emergency) Your PCP will provide or arrange for

urgent care


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Emergency vs. Urgent Care Examples of an emergency:

A head injury

A possible broken bone Bleeding from an injury that doesnt clot and

might need stitches.

Examples of the need for urgent care: Possible ear infection A lingering cough that might be bronchitis


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It helps your providers when You give them all the info they need to give

your child the best care

You askquestions when you dontunderstand You honestly express your concerns You treat them with the same respect you

expect them to give you You use resources wisely (e.g. use HMO 24

hour hotline for urgent, not routine, questions)

You thank them when you like what they do!


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How to Ask Questions

Get member handbooks from each HMO Call member services in each HMO if you

have questions Always keep a record of phone calls and

correspondence. Make copies of everything!Keep a logbook next to your phone and

record the date, name, position/title, andanswer to your questions Be persistent, but try to remain polite!


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Expect your PCP to See to your childs basic health needs

Coordinate medical care, including routine,

preventive, urgent, & specialty Make referrals (& standing referrals)

Take care of prior authorizations

You should keep your PCP informed ofcontacts with other provider visits,including emergency room visits.


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Expect your care manager to

Have experience with people with special

needs

May be one of your best (and most under-utilized) troubleshooting resources Coordinate all your childs services & needs Develop an IHCP with you and your child Help with referrals & locating specialistsYou should call and ask to talk to your

care manager to get a basic care planstarted soon after HMO enrollment!


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What about Co-Pays? Currently, there are no co-pays in

NJs Medicaid managed care system.

However, the proposed budget doesinclude co-pays, and we probably wontknow the outcome until June, 2009.

If NJs new budget does includeMedicaid co-pays, they would startJuly 1, 2009.


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Free Services from Community

Health Law Project Free 74-page booklet, To Your Health:

Your Consumer Rights in Managed Health

Care explains Managed Care Law in NJ. Booklet covers NJ managed care law in

both commercial and Medicaid systems.

Provides samples of what to say on thephone or in a complaint/grievance letter.

To request the booklet call 888-838-3180


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If you have a problem with A provider, talk to your care manager With your HMO not meeting your childs

needs, call: Managed Health Care Consumer Assistance

Program (MHCCAP) 888-838-3180 Helpline - Hours of operation: Mon. thru Thurs. 9:00 5:00; Fri.

9 - 4:00 No charge for assistance in resolving the problem

Medicaid Managed Care Hotline 800-356-1561


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Advocacy An advocate pleads the case of another

When you advocate effectively to meet your

childs needs, you may change a whole system tobetter meet others needs

When you advocate effectively for all childrenwith special needs, you may help make systemswork better for your child and family


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Advocating & Medicaid

Managed Care Enlist allies providers or parent support; take

representation to formal hearings Ask your elected officials to support policies that will

help children with special health care needs Help your child become a self-advocate at whatever

developmental level shes at You are your childs best advocate!


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Dispute Resolution To prevent disputes or misunderstandings:

Learn your Medicaid managed care rights andresponsibilities from your member handbook

If there is anything you dont understand, ask yourPCP, care manager, or HMO member services

Try to resolve problems when and where they ariseby talking openly with the person(s) involved

You can file a complaint, grievance or appeal, oryour PCP or another representative can do itfor you, with your permission


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Dispute Resolution If you cant prevent or immediately resolve a

problem to your satisfaction, call HMO caremanager or member services and make acomplaint. Be specific.

If the problem is not resolved in 24 hours, youmay register a grievance with your HMO byphone or letter

If you are not satisfied with the HMOssolution, call the state Medicaid hotline or theMHCCAP helpline.

Keep records of all contacts!


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Appeals HMO must notify you in writing 10 days

before it denies or limits covered services.

You may file an appeal of the denial with yourHMO. Contact SPANs F2F 800-654-SPAN.

Sometimes appeals are resolved easily, butthe process can become complicated, so youmay want to turn to the Community HealthLaw Project or Legal Services of New Jerseyfor advice.


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Appeals stages Internal (within HMO): two stages

1. With HMO medical director or MD who deniedservices

2. With physicians not involved in 1st internal appealwho might care for children like yours

External (if internal gives unsatisfactoryresults) 3. To NJ Dept. of Health and Senior Services to refer

appeal to an Independent Utilization ReviewOrganization ($2). IURO reviews case & (if it acceptsit) issues a decision to you &/or your PCP, & your HMO.


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Appeals At each stage, if the HMO continues to deny

services, it must inform you in writing withina specified time, giving you reasons for denial and how to proceed to the next stage

At any time during the appeals process, youmay also request a Medicaid Fair Hearing.

Ask for an immediate review in any urgentsituation!

Keep good records of all interactions.


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Medicaid Fair Hearing Within 90 days of service denial, you can file

for a fair hearing

Call the Medicaid Hotline at the NJDepartment of Human Services 800-356-1561 At a fair hearing, an impartial judge listens to

your position. You can bring witnesses and

cross-examine the HMOs witnesses Its a good idea to take legal representation to

the fair hearing. Call Community Health LawProject or Legal Services of New Jersey.


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Resources for Support and

Information Family Voices Resource List: important

literature and phone numbers to help you withMedicaid managed care questions (Fact sheet #6)

Family Voices Fact Sheets Top resources:

Your care manager at your HMO

Medicaid managed care hotline 1-800-356-1561 Managed Health Care Consumer Assistance Program

1-888-838-3180

Medicaid Managed Care Teleconf- For SPAN- 4-1-09%5B1%5D

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