Ch. 4 - How To Make Managed Care Work :: Advocate's Guide to Managed Health Care

This section is organized to provide an understanding of managed care. It will address the following:

Section B.1 - An overview of Managed Care for Medicaid, Family Health Plus, and Child Health Plus
Section B.2 - The six key points of managed care
Section B.3 - How to select a managed care plan
Section B.4 - How to recertify
Section B.5 - Changing managed care plans

Medicaid, Family Health Plus (FHP), and Child Health Plus (CHP) offer services through managed care plans. The shift toward utilizing managed care has become more and more prevalent and most clients will access all or most of their services through managed care plans. Certain clients that are eligible for Medicaid may not have to join a managed care plan, see Chapter 5 for more details.

AN OVERVIEW OF MANAGED CARE

Q. What is managed care?

A: Medicaid, Family Health Plus and Child Health Plus services are offered through managed care plans. Managed care is a way to administer health benefits and create a "medical" home for clients.

It is important to note that clients eligible for Child Health Plus B and Family Health Plus, receive ALL their services through a health plan.

Most Medicaid and Child Health Plus A clients have a managed care plan through which they can access health services. However, certain services are provided directly through Medicaid, not managed care plans. Clients in Medicaid Managed care will have a plan card and a Medicaid card. For the full delineation of services, please see Chapter 5.

Since managed care is the way most clients access services, it is important to understand how managed care works. There are some important considerations when selecting a managed care plan. Selecting a plan can be a daunting process. Before enrolling in a plan, client should familiarize themselves with some basic information on how managed care works. Each plan will be slightly different, but there are certain elements- discussed below- that all plans must adhere to.

For the purpose of this Guide, there are six key points (discussed in Section 4B.2) that clients should be familiar with when selecting a managed care plan. These factors include:

TALKING ABOUT A "NETWORK" IN MANAGED CARE:

For someone who is new to receiving care through a managed care plan or who is new to this country, the idea of a network for health care may need careful explanation. Here are some suggestions on how to approach this discussion:

Ask your client how they have received medical care in the past - Did they go to a clinic, a hospital Emergency Room, the pharmacist or a traditional healer?
Why did they seek medical care? Were they ill or having an emergency? Have they ever gone to see the doctor for a physical or well visit?
Use a creative description: a network is like a...
A clinic without walls: the network is like going to a clinic for both primary and specialty care except that it isn't all in one building. It is a clinic or hospital without walls. The front door is your primary care physician except for emergencies and a short list of "carved-out" services.

Q. How should an individual go about choosing the right managed care plan?

A. The client's satisfaction with managed care largely depends on choosing the right plan. Take time and investigate the different plans that serve the client's community.

A PERSON DOES NOT HAVE TO SIGN UP WITH THE FIRST MANAGED CARE PLAN THAT HE/SHE HEARS ABOUT!

There are 17 Medicaid managed care plans operating in New York City. Many of them are available throughout the City; however, a few do not serve all boroughs.

Before making a choice, find out about each of the plans offered in a client's neighborhood, and consider which is best for the client and his/her family.

A list of the plans and the boroughs which they serve can be found here.

MANAGED CARE FOR MEDICAID, FAMILY HEALTH PLUS, & CHILD HEALTH PLUS

AN OVERVIEW OF MANAGED CARE

TALKING ABOUT A "NETWORK" IN MANAGED CARE:

A PERSON DOES NOT HAVE TO SIGN UP WITH THE FIRST MANAGED CARE PLAN THAT HE/SHE HEARS ABOUT!