Last Updated: April 2008

Q. What type of information does the managed care plan have to give the client to help him/her make his/her choice?

A. Managed Care Plans are required to provide the following information to prospective enrollees:

• How to choose a PCP and how to get care from the plan’s PCPs and specialists;
• How to change PCP;
• How providers are paid by the plan;
• What the client needs to do to get emergency services whenever he/she needs them, 24 hours a day;
• What benefits are covered by the plan, including any limits on benefits and a definition of “medical necessity”;
• When the client will need “prior authorization,” or other plan requirements, before he/she can get treatments or services;
• How to get permission to see (a “referral” to) a specialist outside of the plan’s network, when the client’s plan does not have one with the right training and experience to meet his/her needs.
• How to complain either through “grievance” procedures (for most problems) or through “utilization review” (for denials of medically necessary care).

Q. When does a client need to renew for Family Health Plus?

A. A client must renew his/her Family Health Plus enrollment every year. Clients are not required to renew more than once a year. However, a client is required to report any change in income, family size, residence or health insurance to the Family Health Plus program. The client’s health plan may remind him/her that he/she needs to renew before the year is up