Medicaid Managed Care for Children
with Special Needs in New Jersey

Fact Sheet 3: Provider Relations and Advocacy

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.

Providers

A provider is any professional your child receives medical or other services from, such as Primary Care Providers (PCPs), Care Managers, Primary Care Dentists, other doctors and nurses, social workers, therapists (PT, OT, speech), and other types of health workers.  HMOs, hospitals, and other care facilities are also service providers.

To get the best Medicaid managed care services for your child through your Health Maintenance Organization (HMO), it helps to establish good working relationships with your most central providers, your PCP and your Care Manager.

Your HMO "Rights and Responsibilities" help you know what you can expect from your providers and what they're expecting from you. See your handbook.

You should expect high quality of care and responsibility from your providers, and they should be able to expect responsibility from you, as well.  It helps your providers when you:

• give them all the information that they need in order give your child the best care;

• ask questions when you do not understand;

• honestly express your concerns; and

• treat them with the same respect you expect them to give you.

When you establish open relationships with your PCP, your care manager, and your specialists, you lay a foundation for negotiating with them and eventually building strong working partnerships and mutual trust.

Keeping track of facts:  Some people can learn things better if they take notes.  If you are one of these people, be sure to have paper and a pen or pencil with you when you visit or talk with your child’s providers.  It may also help to have a second adult with you during any stressful meeting with a provider so that the second person can help you clarify what was said at the meeting.

Your PCP:  Work with your child’s PCP to meet your child’s basic health needs.  Your PCP coordinates all medical care, including routine physicals, preventive health services, referrals and standing referrals to specialists, and hospital visits.  Your PCP takes care of prior authorization for some services with the HMO, and he or she can also help you with appeals or preparing for Medicaid Fair Hearings when your HMO denies or limits services.  Be sure to keep your PCP informed of contacts you have with other health care providers, and always contact your PCP within 24 hours when your child has had an emergency room visit.

Your care manager:  Work with your child’s care manager to coordinate all your child’s services and needs.  The care manager will help you and your child establish goals, will develop a comprehensive and personalized Individual Health Care Plan (IHCP) to meet your child’s needs, will help with referrals, special transportation needs your child may have, and coordination of medical care with other services.  Although your care manager should call you shortly after you sign up with your HMO, you don’t need to wait for the call.  Call HMO member services and tell them you want to talk to your care manager.  That way, you can get a basic plan started before any needs arise.  

State regulations require that care managers’ education and experience with people with special health care needs increase with the complexity of client needs, so your child’s care manager will probably be one of your best resources for information and troubleshooting.

Pharmacy:  Fill your prescriptions only at participating provider pharmacies. Your child is entitled to medically-necessary medications at no cost. If you are asked to pay, or if your child’s medications are not in your HMO’s formulary, talk to your care manager to resolve the problems.

Read your member handbook so you understand how and where to get meds.\

• If you have a problem with a provider, talk to your care manager, your PCP, or the Health Benefits Coordinator (1-800-701-0710, toll-free)

• If you have a problem with your care manager or your PCP, call your HMO’s member services

• If your HMO does not meet your child’s needs, call the Medicaid Managed Care Hotline at 1-800-356-1561,or the Managed Health Care Consumer Assistance Program (MHCCAP) at 1-888-838-3180 (toll free).

ADVOCACY

An advocate is someone who pleads the cause of another, or champions another person’s needs.  Building good provider relations is an important way you advocate for your child.

Because you know your child’s and your family’s needs better than anyone, you may be the best advocate for your child.  You can also encourage your child to advocate for himself.  One way he can learn advocacy skills is by observing you, but also provide opportunities for him to speak for and advocate for himself with providers to whatever extent he can.

To Be A Better Advocate

• Gather information.  Ask questions.

• Know your rights

• Keep organized records

• Trust that you may see things professionals can’t, since you’re with your child most of the time

• Be open to learning new things from providers

• Enlist allies:  One powerful way to advocate for your child is to seek support from other people:

• other families of children with special needs can share their experiences and what they have found helpful.  See the Family Voices Resource List.

• your PCP, specialist physician, and your care manager can advocate with you or for you (on your request) with your HMO to meet your child’s needs.

• take an attorney or other advocate with you for any kind of formal hearing.  Check the Family Voices Resource List to locate support or free legal services.

• Find opportunities to help change systems: 

• volunteer to join or serve as a consultant to your HMO consumer advisory board

• offer to participate in State agency consumer advisory groups working to develop and improve policies and regulations that benefit people with special needs in Medicaid managed care.  Some NJ State agencies are listed on the Family Voices Resource List.

• write or phone your local, state or national officials and ask them to support laws and regulations that safeguard Medicaid for children with special needs and their families.  When the officials do, call or mail them with a “thank you.”  

Being an advocate for your child means doing what’s necessary to make sure your child gets what he or she needs, and your family gets what it needs to care for your child.

• Thank your providers when you like what they do; too often they only hear from dissatisfied clients.

• Keep your child’s provider phone numbers near your phone, along with her insurance card, history, medications list, and any other information you may need when you make calls.

• When you call your provider with urgent needs, be specific about symptoms such as fever, how long your child has been sick, whether others in household are sick, etc.

• Use resources wisely – for example, call the HMO’s after-hours hotline only with urgent, not routine, questions.