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Shift From Medicaid to Managed Care: FAQ

Question: If I am a Medicaid recipient, do I have to enroll in a managed care plan, such as a Health Mintenance Organization (HMO), to continue receiving Medicaid?

Answer: This will depend on the terms of the approval your state got from the federal government to begin managed care. It also depends on whether your state with permission from the federal government, decided to offer managed care for all Medicaid recipients.

You may be in a state, region, or belong to a group of recipients where managed care is available, but not mandatory. Managed care organizations may try to sign you up, but do not assume that you have to join. If you have any doubts about joining, contact your Medicaid caseworker, or the office that administers your Medicaid, and find out the answers to your questions.

Question: If I am required to sign up for managed care, or if I choose to do so, do I have a choice in what plan to join?

Answer: Again, this depends on what arrangements your Medicaid program has made. Often you will have a choice of plans, but you should clarify this with your Medicaid agency. Again, do not let a managed care plan pressure you to join that plan.

Question: If I have a choice in plans, what should I look for in making my selection?

Answer: A lot depends on your particular circumstances and needs. Making the best selection may require tradeoffs - sacrificing something you want in order to receive something that you want more. For example, if transportation is an issue for you, you may decide to choose a plan that has practitioners and facilities located nearby, even if that means giving up something else by selecting that plan.

If you care most about being able to stay with your own physician, you will want to see if any available plan offers that choice. If you care about access to specialists, then you need to know how the managed care organization (MCO) handles specialist referrals: whether your primary care physician must make them, whether the MCO must approve them or whether you can make the referral for yourself and go to a specialist when needed. No plan is going to be perfectly tailored to meet all of your needs.

You should also evaluate and compare the services, supplies and treatments covered by the plan. Determine which plan covers will best provide for the specialized services that you need. If a plan does not routinely cover certain services, find out what the procedures are (if any) for obtaining authorization for services when they are needed. If your disability relates to hearing, you will want to ensure that the plan includes audiology services. If you have a communication disability, then speech-language services might be most important. In other contexts, physical or occupational therapy, ophthalmology, psychiatry, chiropractic, nutritionist or any number of other services and practitioners may be your principal concern.

Find out how helpful the MCO is when you contact them by phone. Tell the operator that you are a patient who has lost your member identification number. See if they offer to look it up for you, or if they tell you to call back once you have found it.

Determine whether they deal with complaints or requests for approval of services quickly. Ask other people about their experiences who have been enrolled in that plan.

You should determine answers to the following questions about each plan:

What are the provisions for dropping their coverage and switching to another plan?
What is your right to change primary care physicians?
Do they have a staff person assigned to handle complaints or to coordinate care where exceptional or unusual services are involved?

The fact that the plan covers the particular kind of service or practitioner you need does not necessarily tell you how they define that service. You need to try to find out if the MCO places limits on the service or defines it narrowly.

Question: What do I do if I have a problem that the MCO cannot solve to my satisfaction?

Answer: Decisions about care may not always be to the patient's satisfaction. Still, if you think your well-being is jeopardized, or that the MCO is acting differently than you were led to expect, you may need to look for assistance in getting a full hearing or a better decision.

You may need to find out what state agency monitors the performance of the Medicaid MCO. Remember, the MCO is operating under a contract with the state, which pays them a substantial amount of money to provide services. Start with the Medicaid agency. Do they regard it as their job to accept and investigate complaints about the performance of a Medicaid MCO? If not, whose responsibility is it? The merit of your claim only becomes an issue when you have found the proper person or office.

The state Medicaid agency may not want to get involved and may tell you to go back to the MCO. If that happens, and if you have already tried going through the MCO itself, you may need to get in touch with your state legislator. You may want to ask them to contact the Medicaid agency about doing its job. The state government has the authority and the duty to make sure that the Medicaid MCO is complying with its state contract and with the Medicaid law.

Question: How do I get information about the details of a plan?

Answer: The MCO will have a variety of written materials available, including the contract and the various rules and documents showing what they cover and how they operate. You should read all of these materials before signing up for any plan. If you read in a language other than English, you have the right to request that the materials be made available in another language. You also have the right to request documents in an alternate format. If the language is too complicated or legalistic, ask for an explanation in simpler terms.

If you need someone in the advocacy community, you might try a local independent living center, a local UCP affiliate or any organization to which you belong or that you know about in your community. Your state Medicaid agency or Protection and Advocacy agency may have published some background material that can help you too.

Question: If I have a choice, should I go into managed care or stay with my old plan?

Answer: Whether you should join depends on how happy you are with your current coverage; what you can find out about the available managed care plans and their providers; and what incentives your state is offering to convince you to join.

Revised 8/01

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