Navigating Managed Care 1

PARTNERING WITH PROVIDERS

Work to build strong, trusting relationships so providers really stand behind you, your child, and your family

Good relationships with committed providers relieve you of some of the stress of coordinating all the services your child needs, and provide support for problem resolution

Expect quality care and responsibility from your providers, and show them you are responsible too

Navigating Managed Care 2

Understand your entitlements Read your member handbook to learn

your rights and responsibilities which services are available to your child which services require referrals or prior

authorization how and where to order medications and

durable medical equipment who to call with questions or complaints

Navigating Managed Care 3

It helps your providers when you

give them all the info they need to give your child the best care

listen actively; take notes to help understand ask questions when you don’t understand honestly express your concerns treat them with the same respect you expect

them to give you use resources wisely (e.g. use 24 hour hotline for

urgent, not routine, questions) keep or reschedule appointments thank them when you like what they do!

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Expect your PCP to… See to your child’s basic health needs Coordinate medical care, including

routine, preventive, urgent, & specialty Make referrals (& standing referrals) Take care of prior authorizations Help with appeals or fair hearingsYou should keep your PCP informed of

contacts with other provider visits, including emergency room visits.

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If you have Medicaid managed care, expect your care manager to… have experience with people with special needs probably be one of your best troubleshooting

resources coordinate all your child’s services & needs develop an IHCP with you and your child help with referrals & locating specialistsIf you are enrolled in Medicaid Managed

Care, you should call your care manager to get a basic care plan started soon after HMO enrollment.

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If you have a problem with…

A provider, talk to your care manager or PCP Your care manager or your PCP, call your

plan’s member services With your plan not meeting your child’s

needs, call Medicaid Managed Care Hotline 800-356-1561 or Managed Care Consumer Assistance Program

(MHCCAP) 888-838-3180

Navigating Managed Care 7

The MEDICAL HOME*

is not a place or building! is an approach to providing high-

quality, cost effective health services;

is a coordinated & respectful health care partnership among a child, his/her parents and the child’s Primary Care Provider (PCP)

*Initiative funded by MCH Bureau & HRSA

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Qualities of a Medical Home…

Accessible Family-

centered Continuous Comprehensive

Coordinated Compassionate Culturally

Competent

Navigating Managed Care 9

Medical Home Program Areas… Access to a

medical home Early and

continuous screening

Community based systems of care that are culturally competent

Access to affordable health insurance

Family & youth participation & satisfaction

Services necessary for transition to adulthood

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The Medical Home Program is being funded to…

establish statewide models of medical home implementation

work with PCPs to expand the medical home concept in their practices

develop strategies for better coordination between primary and specialty care

establish mechanisms for coordination between the medical home and other community services

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The Medical Home Program is measuring results…

% of children with special needs in each state with a medical home

more specific data about children and medical homes in a national survey

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Your child with special needs can have access to a Medical Home…

Ideally, through a knowledgeable PCP willing to work with you and your child to identify and access all the services your child and family need to reach your maximum potential

Whatever the practice setting, the provider’s services must meet the American Academy of Pediatrics criteria for a Medical Home

Navigating Managed Care 13

Medical Homes:the key to success

Families and providers collaborating as partners

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Health InsuranceDISPUTE MANAGEMENT

Try to prevent disputes or misunderstandings: Learn your rights and responsibilities from your

insurance plan’s member handbook If there is anything you don’t understand, ask your

PCP, care manager, or member services Try to resolve problems when and where they arise

by talking openly with the person(s) involved You can file a complaint, grievance or appeal, or

your PCP or another representative can do it for you, with your permission

Navigating Managed Care 15

Dispute Resolution… If you can’t prevent or immediately resolve a

problem to your satisfaction, call member services and make a complaint. Be specific.

If member services can’t solve the problem in 24 hours, you may register a grievance with your plan by phone or letter (procedure in member handbook)

If you are not satisfied with the plan’s solution, you can call the MHCCAP helpline (or if you are a Medicaid participant, the state Medicaid hotline)

Keep records of all contacts!

Navigating Managed Care 16

Appeals HMOs must notify you in writing 10 days

before they deny or limit covered services. You may file an appeal of the denial with

the HMO. Sometimes appeals are resolved easily, but

the process can become complicated, so you may want to turn to your care manager or to the Community Health Law Project or Legal Services of New Jersey for advice.

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Appeals – stages Internal (within insurance plan): two stages

1. With plan’s medical director or MD who denied services

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

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

appeal to an Independent Utilization Review Organization (for small fee). IURO reviews case & (if it accepts it) issues a decision to you &/or your PCP, & your HMO.

Navigating Managed Care 18

Appeals … At each stage, if the plan continues to deny

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

Medicaid participents: at any time during the appeals process, you may also request a Medicaid Fair Hearing.

Ask for an immediate review in any urgent situation!

Keep good records of all interactions.

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Help with disputes Managed Health Care Consumer

Assistance Program (MHCCAP) 1-888-838-3180 toll free

Medicaid Hotline 1-888-356-1561 toll free

Community Health Law Project 1-973-275-1175

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An Advocate is

someone who championsanother person’s needs.

Being an advocate for your child means doing what is necessary to make sure your child gets what he or she needs and that your family gets

what it needs to care for your child.

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Enlist Alliesin advocating for your child

Other families of children with special needs can share their experiences and what has helped them; ask them*.

Your child’s providers can be powerful advocates for your child; build good relationships with them.

An attorney or other advocate can go with you for any formal hearings; take them*!

(*see Resource List)

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Advocating for your child in Managed Care

Ask your child’s providers PCP, specialist, or care manager to advocate with you or for you for needed or denied services

Volunteer for HMO consumer advisory boards State agency consumer advisory groups

Ask your elected officials to support policies that will help children with special health care needs

Navigating Managed Care 23

Your Child and Advocacy Help your child become a self-

advocate at whatever developmental level she’s at; don’t always speak for her. Let her do it herself if she can.

Other than your child, you know your child best and are his best advocate; don’t be afraid to speak up for him.

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Benefits of Advocacy When you advocate effectively for

your child’s needs, you may change a whole system to better meet other children’s needs

When you advocate effectively for all children with special needs, you may help make systems work better for your child and family