Navigating Managed Care1 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 Care2 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 Care3 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!

Navigating Managed Care4 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 hearings You should keep your PCP informed of contacts with other provider visits, including emergency room visits.

Navigating Managed Care5 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 specialists If you are enrolled in Medicaid Managed Care, you should call your care manager to get a basic care plan started soon after HMO enrollment.

Navigating Managed Care6 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 or Managed Care Consumer Assistance Program (MHCCAP)

Navigating Managed Care7 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

Navigating Managed Care8 Qualities of a Medical Home… Accessible Family-centered Continuous Comprehensive Coordinated Compassionate Culturally Competent

Navigating Managed Care9 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

Navigating Managed Care10 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

Navigating Managed Care11 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

Navigating Managed Care12 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 Care13 Medical Homes: the key to success Families and providers collaborating as partners

Navigating Managed Care14 Health Insurance DISPUTE 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 Care15 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 Care16 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.

Navigating Managed Care17 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 1 st 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 Care18 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.

Navigating Managed Care19 Help with disputes Managed Health Care Consumer Assistance Program (MHCCAP) toll free Medicaid Hotline toll free Community Health Law Project

Navigating Managed Care20 An Advocate is someone who champions another 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.

Navigating Managed Care21 Enlist Allies in 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)

Navigating Managed Care22 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 Care23 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.

Navigating Managed Care24 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