HEALTH CARE

What is Medicaid Managed Care? (Part I)
By Lauren Shapiro & Domenique Ghossein
(Consumer News, Vol. 1, No. 4, April 1996)

This passage, published in Consumer News' April 1996 issue, is the first part of the entire article by L. Shapiro & D. Ghoosein. The second part, in Consumer News's May issue of 1996, appeared in the "Conflict Resolution" section. (Click here to go to Part II if you have already read Part I below.)

Medicaid Managed Care is a special program that allows -- and sometimes requires -- Medicaid recipients to join a managed care plan.

Most Medicaid recipients can choose to go to any doctor who accepts Medicaid. Medicaid then pays that doctor directly for the service. They call this "fee-for-service." With regular Medicaid, if you think you need a second opinion or want to see a specialist, you can make an appointment with any doctor who will accept Medicaid.

Under Medicaid Managed Care, Medicaid recipients join a managed health care plan. They assign a doctor who makes decisions about your care. Medicaid Managed Care is Different from Regular Medicaid in several basic ways. This article explains what Medicaid Managed Care is, who must enroll in Medicaid Managed Care, and if you do enroll, what your rights are.

How is Medicaid Managed Care different from regular Medicaid?

Provider List. When you join a managed care plan, you can use only doctors that are members of the plan. If you go to a doctor who is not in the plan, Medicaid will not cover the visit. A few exceptions to this rule are: HIV testing, pre and post-test counseling from any provider.

Primary Care Provider (PCP). With a managed care plan, you will have a primary care provider -a doctor or nurse- who will monitor your health. You must get permission from your PCP to see a specialist or have a second opinion.

Flat Fee. Medicaid pays the plan one flat fee to take care of all of your health needs. The managed care plan gets the same amount of money from Medicaid whether you go to see the doctor once during the month or ten times. For this reason, the plan will try to keep your medical care and expenses to a minimum. In some ways, this is good for you because they have more of an incentive to prevent you from getting sick. Yet the system can be harmful because there is an incentive not to pay for medical procedures or care unless it is absolutely necessary.

Emergency Room Visits. Under the current Medicaid system, many patients go to the emergency room to get treated for conditions that are not emergencies. Medicaid pays for the emergency room visit. Under a managed care plan, they will only pay for emergency room visits if there is a true emergency. This can mean an injury from an accident or a serious illness that can cause permanent damage or death.

How quickly can I get a Medical appointment under Managed Care?
Under the managed care plan, you can see a doctor or a nurse practitioner within forty-eight to seventy-two hours if there is a need for urgent care. This can include a fever or influenza. For routine care, such as pap smears or immunizations, you can expect to see a doctor within four to six weeks.

How can I find out more about Medical Managed Care Plans?
There are lots of different managed care plans in New York City. Some examples are Aetna, Centercare, Cigna, Healthnet, Health Plus, Healthy Start, Metropolitan Health Plan, Oxford, and US Healthcare. To find out more about each plan, you can go to the enrollment and education units in welfare centers throughout the city. You can also call 1-800-505-5678 if you live in New York City. You can also find them through this web site.

Some Things to Think About if You are Living With HIV Disease or AIDS
Managed care is supposed to provide preventive care, keep healthy people healthy, and save costs. Because someone who is HIV positive is likely to need frequent referrals, specialists care, and lab tests, you should think very carefully before joining a managed care plan. You then decide whether a plan is likely to meet your needs. If possible, you should list the complete range of services that you are using now and then decide whether a plan is likely to meet your needs. If possible, you should speak with a patient of the plan [who is a person living with AIDS] to ask about their experiences.

The Primary Care Provider
When you join a managed care plan, you have to choose one of the plan’s doctors to be in charge of your care. This doctor is called your primary care provider. She or he will give you regular preventive care like routine check ups.

A study, published by the Journal of American Medical Association, shows that only 25.8% of primary care physicians surveyed could detect and diagnose common symptoms of HIV-related disease. In a recent survey of 20 managed care plans by Housing Works Inc., It was found that 95% of the plans could not refer a potential client to a primary care provider with experience treating HIV and AIDS. This is some thing you should ask the plan about before enrolling. How many [member] doctors have experience treating patients with HIV/AIDS? Where are they located? If the plan cannot answer these questions, think again about choosing this plan.

Specialists
Under the managed care plan, if you want to see another doctor in the plan or see a specialist, you must first get permission from your primary care provider, if you do not get permission, Medicaid will not pay for the care and you may get billed. If you need frequent referrals to a specialist, and many people with HIV do, a managed care plan may not be the best option for you.

If you are living with HIV disease or AIDS you may be seeing a specialist. Examples are a gastroenterologist, an infectious disease specialist, a mental health specialist, or psychiatrist. Ask your specialist if she is associated with a managed care plan. Remember, if you are enrolled in a plan, you can see only the doctors within that plan. If you do not see any specialists now, but think you may need one later, ask the plan for their list. Find out where they are located. If you know someone in the plan, ask what their experience is with specialists while they have been in the plan.

If you do not have a primary care provider or want to change your provider, you may want to ask the plan for their list of available providers and their locations. If you do not speak English, you should ask whether any primary providers speak your language.

Pharmacies are often part of a managed care plan. If you are considering enrolling in a managed care plan, you should find out which pharmacies near you participate in the plan or whether you can use your Medicaid for drugs.

For more information call:

Medicaid Managed Care Client Services Office:
(212) 941-5112
 
The HRA Helpline:
(800) 505-5678

Consumer News will continue this discussion in subsequent issues, and will link other articles and information through our web site. If you write or e-mail your concerns, we will record your questions/complaints and help you to find answers to your questions.

Click here to continue reading this article (Part II) in the Conflict Resolution section.