GETTING NEEDED SERVICES FROM YOUR MANAGED CARE PLAN Workshop for Parents and Providers A Partnership between Parents’ Place of Maryland and Georgetown University Center for Child and Human Development MFAI is funded by Grant No. 1 H93 MC from the Division of Services for Children with Special Health Care Needs, HRSA, U.S. DHHS Presented by: Maryland Family Access Initiative

About Parents Place of Maryland How do we help? Education Information Technical assistance Supportive activities

About Georgetown University Center for Child and Human Development The Center provides research, training, policy analysis and development, and technical assistance.

Objectives Know the services available through your MCO Understand steps needed to access those services Learn what to do when services are initially denied Know methods of documentation and record keeping, and their importance

Primary Care Provider (PCP) PCP may be Pediatrician Family Practice doctor Pediatric nurse practitioner Other Review MCO provider panel Talk with other families Check location, hours, languages spoken, etc.

Choosing Your Child’s PCP Review your member handbook and roster of participating providers Interview the doctor you are considering Know what questions to ask Carefully choose your provider

Interpreters Essential for some families Don’t rely on child to translate May be on staff or specially arranged May be arranged by office, MCO or family

Knowing What Services and Providers are Covered Carve-Outs Medical Necessity Referrals and Authorization Process

Pediatric Specialist Children with special needs require one or more Review MCO provider panel Check hospital affiliation Determine MD’s experience with your child’s special need Talk with other families Includes mental health provider

Therapists Occupational therapist (OT) Physical therapist (PT) Speech and language pathologist Vision specialist Respiratory therapist (Same process as pediatric specialist above)

Mental Health Providers Refer to your Provider Handbook Learn if Mental Health is a Carve-out Call several Mental Health providers listed in your handbook Ask lots of questions, I.e. Do they treat children

Other Providers Home health agencies Medical Supply and equipment vendors Transportation Case managers X-ray and lab

Services your child may need and those that are covered Prevent/primary care Specialized treatments After hours/emergency In-patient X-ray/lab Home-based Medical equipment Mental health Medication Transportation

Sources of Information - 1 Member handbook Provider directory Case managers Websites Policy documents

Sources of Information - 2 Employer summaries and human resource departments Hotlines Contact with other families Formulary listings Other?

Steps for Obtaining Services 1. Scheduling appointments 2. Keeping appointments 3. Obtaining referrals and authorizations 4. Filling prescriptions and obtaining refills 5. Requesting assistance from your MCO

Keep Documents and Records - 1 Methods of record keeping Maintain written log Records of phone calls Create a paper trail Keep everything and throw nothing away

Keep Documents and Records - 2 Save copies of Referrals Approvals Authorizations Denials Keep everything and throw nothing away

Keep Documents and Records - 3 School records Test results Record all diagnoses Medical reports Keep everything and throw nothing away

Strategies -1 Maintain open communication Establish relationship with PCP Know what is carved-in Know what is carved-out Learn conditions for approval

Strategies - 2 Communicate with referral providers Call member hotlines Understand how medical necessity is determined Understand who determines medical necessity

Strategies - 3 Appeal decisions Request second opinions Determine who is responsible for mental health Learn how mental health access differs from medical services

Questions and Discussion