Choosing a Health Plan for Children with Special Health Care Needs

1. Choosing a Health Plan for Children withSpecial Health Care Needs Presented by: Maryland Family AccessInitiative 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 00072 from the Division of Services for Children with Special Health Care Needs, HRSA, U.S. DHHS

2. About Maryland Family Access Initiative • A project funded by the federal Maternal and Child Health Bureau to • assist families to access comprehensive services from managed care organizations which meet all needs of their children with SHCN, • and to ensure their enrollment in the plan best suited to their individual needs.

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

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

5. What you will learn in this workshop • Types of health plans and how they work • Identifying your service needs • Finding a good fit • How to compare costs of plans • How to compare ease of use of plans • How to read health plan materials • Making a decision

6. Where Do I Get These Health Plans? • Group Policies • Individual Policies • Medicaid • Medicare

7. Types of Health Plans • Fee for Service • You pay and plan reimburses (except Medicaid and Medicare) or pays provider directly • Often open choice of any provider • Few requirements for pre-authorization • Rarely available in its original form—even these plans now “manage care”

8. Types of Health Plans • Health maintenance organizations (HMOs) • Designed to include preventive care • First to offer prescription benefits • Have a set group of doctors and providers that must be used (except in unusual circumstances)

9. Types of Health Plans • Health maintenance organizations (HMOs) • Need referral/approval for all but primary care services • May have all doctors in one place • Low out -of -pocket -costs

10. Types of Health Plans • Preferred Provider Organizations (PPOs) • Most common now • Have contracts with a list of doctors, hospitals, other providers who agree to see their enrollees for a discounted fee • Best coverage is for doctors “in the network” • Much higher out-of-pocket costs to go out

11. Type of Health Plans • PPOs • Some, called Point of Service (POS) plans • May have prescription benefits • Often a co-pay for doctors and co-insurance for other services

12. Medicaid • Medicaid has several different types of plans. • Most on Medicaid, not in a special program, have choices of managed care plans

13. What are your service needs? • Make a list of the services your family needs. Include: • Doctors/specialists • Therapists • Hospitals • Home care • Equipment

14. Pre-existing Condition A pre-existing condition is a medical condition diagnosed or treated before joining a plan. In the past, health care given for a pre-existing condition often was not covered for someone who joins a new plan until after a waiting period.

15. Medical Necessity • While a service may be listed as covered, it does not mean the plan will always pay for it. • It must be “medically necessary” according to the plan. Read the plan’s definition of that term, but in the end, it is their interpretation that decides.

16. Medically Necessary Services and Supplies THE PLAN WILL NOT MAKE PAYMENTS IF THE SERVICE OR CARE WAS NOT MEDICALLY NECESSARY. The Plan reimburses only for Covered Services which are Medically Necessary. Again, you are protected when you use a Network Provider. If the Plan determines that a service is not Medically Necessary, either before or after it is provided, the Network Provider will be prohibited from billing you for that service. either before or after it the Network Provider will be prohibited from billing you for that service.

17. continued Out-of-Network, you are not protected. If the Plan determines that a service is not Medically Necessary either before or after it has been rendered by an Out-of-Network Provider, the Plan will not cover those charges. The Provider will have the right to bill you, and you will be responsible. Provider will have the right to bill you, and you will be responsible.

18. continued The Plan will not make any payment for care which is not Medically Necessary. In cases where the Plan determines that services or care were rendered in an inappropriate setting (e.g., admissions to a hospital for care which could have been provided safely in a doctor’s office), the Plan will pay only the amount the Plan would have paid for care in the more appropriate setting. inappropriate setting (e.g., admissions to a hospital for care which could have been provided safely in a doctor’s office),

19. continued The Plan’s determination of medical necessity will be made after considering the advice of trained medical professionals, including the Plan Medical Director, who will use medically recognized standards and criteria to evaluate the medical necessity of such services. In making the determination, the Plan will examine the circumstances surrounding your condition and the care provided, including your provider’s reasons for providing or prescribing the care, and any unusual circumstances which are brought to the Plan’s attention. However, the fact that your physician prescribed the care or service does not automatically mean that the care is Medically Necessary or that it qualifies for payment under this Plan. medically recognized standards provider’s reasons for providing or prescribing the care, and any unusual circumstances which are brought to the Plan’s attention. However, the fact that your physician prescribed the care or service does not automatically mean that the care is Medically Necessary or that it qualifies for payment under this Plan.

20. Home Health Care The Plan will cover Medically Necessary home health care visits by home health agency personnel in your residence. The Plan will pay for up to ninety (90) visits per calendar year. In-Network home health care visits are paid in full. Out of Network, you pay 20% of Covered Charges after the annual Deductible. If home health care is recommended by an Out-of Network Physician, you must get advance approval from the Plan before receiving home health Care. Medically Necessary In-Network Out-of-Network Covered Charges Deductible

21. Assessing the Provider Network • Take your list of needs and compare it to what the plan provides. • Check the list of network providers (often in a book or on web site) • Read the plan manual for what is included

22. Physical Therapy The Plan will cover up to twenty (20 visits per year for Medically Necessary physical therapy services. cover Medically Necessary

23. Speech and Occupational Therapy Plan will cover up to a combined total of twenty(20) visits per year for Medically Necessary speech therapy and/or occupational therapy. Speech therapy is covered if it is needed to restore speech when there has been a functional loss of speech due to acute trauma, infection or other pathological diseases while covered under the Plan. However, the Plan will not pay for speech therapy provided for developmental delay disorders or learning disabilities. Medically Necessary restore speech

24. Understanding Costs • There is more to cost of a plan than premiums. • Co-pays • Co-insurance • Deductibles • Out of plan rates • Limits on dollars/number of visits • Decreasing reimbursement/more visits • Lifetime limits

25. Co-pays • This term refers to the amount you pay each time you visit a doctor and sometimes for prescriptions. Often it is less for a primary care doctor than a specialist. • Even when you meet your deductible you will continue to pay this fee. • In many plans co-pays do not count against your deductible limit.

26. Co-insurance • For most services other than office visits, you will pay a percentage of the fees charged. • Often you pay 20% of costs • Services include lab tests, x-rays, procedures, hospital and surgery fees, etc.

27. Deductible • Most policies (not all HMOs) have a deductible. • You pay all costs up to this amount, then co-insurance starts. • Low premium plans often have high deductibles.

28. Out-of-Plan Rates • Using services out of plan is usually more expensive. • Co-insurance rather than co-pay • Doctors not in the plan do not have to accept discounted rates.

29. Out-of-Network Hospitals and Other Health Care Facilities When you access Out-of-Network hospitals and other health care facilities, your hospital and other health care facility Benefits, both inpatient and outpatient, will be based on the Covered Charges billed by the facilities. The Plan may pay the provider directly for Covered Services provided by the Out-of-Network Provider. You must pay 20%-25% Coinsurance on the Covered Charge plus the entire amount of any difference between the Covered Charge and the actual charge. Covered Charges 20%-25% Coinsurance on the Covered Charge plus the entire amount of any difference

30. continued The Plan will pay no more than the Covered Charge for any Covered Service or supply. This means that, if your physician or the provider charges more that the Covered Charge, you remain responsible for the amount charged in excess of the Covered Charge and this amount will not be credited towards your annual Out-of-Pocket Maximum. remain responsible for the amount charged in excess of the Covered Charge and this amount will not be credited towards your annual Out-of-Pocket Maximum.

31. Dollar/Visit Limits • Mental Health Services are often limited by number of sessions or decreasing reimbursement • Some services have a dollar limit • Some plans have lifetime limits, may be different for mental health services

32. Example of Mental Health Benefits OUTPATIENT (52 Visits per year) Visits 1-10 Deductible + 20% Coinsurance Visits 11-20 Deductible + 30% Coinsurance Visits 21-52 Deductible + 50% Coinsurance

33. How are claims filed (you or provider) How long until a claim is paid? What do you do if you have a problem? What is the appeals process? Care coordinators for CSHN? Ease of Use

34. Medical Claims: When you use Network Providers, you are free from all the hassles of filing claims and waiting for reimbursement. The Network Provider will file claims with the Plan and will collect from you any applicable Copayment and charges not reimbursed due to Deductible or Coinsurance or non-Covered Services. When you use Out-of-Network Providers, claim forms will need to be submitted either by you or the Out-of-Network Provider. Call Customer Service at 1-888-409-2763 (TOLL FREE) for assistance with submitting claims. Network Providers, you are free from all the hassles of filing claims and waiting for reimbursement. Copayment Out-of-Network Providers, claim forms will need to be submitted either by you or the Out-of-Network Provider.

35. Mental Health/Substance Abuse Claims: You are responsible for the claims paperwork for Mental Health/Substance Abuse claims. You are responsible for the claims paperwork for Mental Health/Substance Abuse claims. Call Customer Service at 1-888-409-2763 (TOLL FREE) for assistance with submitting claims.

36. Sorting out the information • Systematically compare plans • Services/networks • costs in each area. • Compare ease of use. • Then pick a “direction”.

37. Contact US Parents’ Place of Maryland 801 Crowell Park Drive, #103 Glen Burnie, MD 21061 Tel: 410-768-9100 Fax: 410-768-0830 Web: www.ppmd.org E-mail: info@ppmd.org