Medicaid Managed Care for Children
with Special Needs in New Jersey

Fact Sheet 2: Choosing Providers

When we talk about Medicaid managed care, some unfamiliar words may come up.  Go to the “Important Terms” fact sheet  to look up highlighted words.  This will help you learn how to “speak the language” of managed care.

Two levels of choice

When you enter the Medicaid Managed Care system in New Jersey, you will need to make two important decisions:

1.  Which of the 5 Health Maintenance Organization (HMO) plans offered under Medicaid Managed Care is the best one for your child?

2.  In the HMO you choose, who is the best Primary Care Provider (PCP) for your child?

New Jersey Care 2000+, the state Medicaid Managed Care Program, will mail you information about each HMO to help you choose among them or you can request this information. Read these booklets carefully.

The HBC can make home visits.

HELPFUL APPROACHES

List all the people who provide services to your child.  Consult with your current providers or the HBC to determine which HMO(s) Provider Networks they are in.  Choose the HMO with the largest number of your current providers, or with the current provider(s) who are most important to you and your child.

Ask questions about the different plans, and choose the plan that meets most of your requirements.

Talk to family and friends, especially ones with similar health care needs, about their experiences with making choices in managed care.

The Family Voices Resource List provides helpful contacts who can answer your questions.

TROUBLESHOOTING

HMOs are encouraged to invite your current providers to join their provider network if they not members.  Ask member services at any HMO you are interested in about this possibility.

The family of a child with complex special health care needs who has an outstanding system of providers who do not belong to any of the Medicaid HMO networks may request an exemption to Medicaid Managed Care.  Ask the HBC how to do this.

Before choosing an HMO, you may want to ask questions like these about it:

Are the doctors I want for my child in the HMO?  Ask your doctor, the HMO’s member services, or the HBC.

Is the hospital I use in the HMO provider network?

Does the HMO provide services in convenient locations for me -- not just the PCP, but also pharmacy, laboratory, medical equipment, and specialists?

1.  If my child needs a specialty clinic for a particular disability (like spinal cord injury or cerebral palsy), is the specialty clinic in the HMO network?

2.  Or will the HMO be willing to refer my child outside the network to this clinic?

Is a network pharmacy accessible to me?  Is my current pharmacy in the HMO’s network?

What dental services are provided, and are they convenient/accessible to my child?

Are my current durable medical equipment suppliers in the HMO’s network?  If not, how will we get DME we already own maintained through the HMO?  (Ask to talk to a care manager.)

Do 24-hour hotlines and member services have TDD or phone relay services?

Are there providers who speak my language?  What are the provisions for interpreters?

What are the provisions for sign-language interpreters?

Does the HMO have additional benefits that are particularly attractive for my child?

You may change HMOs if you have major problems.  Call the HBC to process changes. 
It can take 45 days or more to make the switch.

Before choosing a PCP, you may want to ask questions like these:

Does the provider have experience working with families of children with special health care needs?

Has he/she worked with children with my child’s disability or special needs before?

Who will see my child when the PCP is not available?

Is the provider’s office located close to my home?

Are the office and exam rooms easily accessible or are there barriers for my child and me?

Does this provider speak my language or sign?

Once You’ve Chosen a Plan and a PCP

Read your member handbook carefully.  It will answer many of your questions.

Identify important people and phone numbers to call, and keep these posted next to your phone.

• member services

• 24-hour hotline for questions

• your PCP

• your care manager

Be sure you learn how to reach help after hours!

Continue to keep records of all contacts with your PCP, care manager, and others so you can follow up effectively, or so you know the people you rely on are following up on your issues.  If any problems come up, you can use these records as documentation of what you’ve done to try to resolve them.

You may change PCPs if you are not satisfied with your first selection.  Talk to your HMO’s member services, or call your care manager for information.

How to Ask Questions 

Before you start, read the materials you receive from Medicaid in the mail.  They compare the different HMOs, as well as consumer satisfaction with the different HMOs. 

Include your child – to the best of his or her ability – in the selection process.  This can be a great opportunity to help your child learn some basic self-advocacy skills. 

Get member handbooks from each HMO so that you can compare the HMOs in detail.  The numbers to call are listed on the Family Voices Resource List.  It can take many weeks and some follow-up calls to receive these handbooks, so start as soon as possible. 

You can call member services at the different HMOs to ask questions.  An HMO care manager or your county case manager may also be able to answer some of your questions. 

Always keep a record of all phone calls and correspondence.  Make copies of letters you send and keep them on file.  Keep a “logbook” next to your telephone, and record the date, the name of the person you talked to, their responses to your questions. 

Be persistent in seeking answers, and try to remain polite as you seek information.  These tactics will serve you and your child well.