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Managed Care Plan Services Workshop: Guidance for Parents & Providers

A workshop presented by Maryland Family Access Initiative and Georgetown University Center for Child and Human Development on accessing and navigating services through managed care plans. Learn about available services, choosing a primary care provider, understanding documentation, and more. Get valuable insights on accessing specialists, mental health providers, interpreters, and critical services your child may need. Discover strategies for maintaining records, obtaining referrals, filling prescriptions, and advocating for your child's healthcare needs.

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Managed Care Plan Services Workshop: Guidance for Parents & Providers

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  1. GETTING NEEDED SERVICES FROM YOUR MANAGED CARE PLAN Workshop for Parents and Providers 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 Parents Place of Maryland • How do we help? • Education • Information • Technical assistance • Supportive activities

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

  4. 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

  5. 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.

  6. 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

  7. 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

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

  9. 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

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

  11. 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

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

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

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

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

  16. Steps for Obtaining Services • Scheduling appointments • Keeping appointments • Obtaining referrals and authorizations • Filling prescriptions and obtaining refills • Requesting assistance from your MCO

  17. 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

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

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

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

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

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

  23. Questions and Discussion

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