Medicaid Managed Care for Children
with Special Needs in New Jersey

Fact Sheet 2: Important terms

GENERAL

Medicaid: a joint Federal-State program (Title XIX of the Social Security Act) which pays for health care services for low income families with dependent children, senior citizens, and people with disabilities, as well as some people who are medically needy because their health expenses are high.  The Federal government regulates and oversees Medicaid, and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services administers Medicaid in the state. 

Managed Care:  a comprehensive system of health care delivery and financing which coordinates and provides timely access to high-quality, medically-necessary health care services for its members in a cost-effective manner. 

Medicaid Managed Care:  the delivery of services to Medicaid-eligible individuals by means of a managed care system. 

New Jersey Care 2000+: the name of the Medicaid managed care program in New Jersey, which is administered by the Division of Medical Assistance and Health Services of the Department of Human Services.

Health Maintenance Organization:  type of managed health care organization that provides coverage of services for enrollees from a specific network of providers in a geographical area for a prepaid, fixed premium. 

Identification card:  a card issued by the HMO to identify enrollees.  This card is different from the Medicaid card.  Both should be presented at time of service. 

Provider Network:  all the doctors, hospitals and other providers an HMO contracts with to provide services to its enrollees.  In order for services to be fully covered by the HMO, enrollees are usually limited to receiving services from its provider network.  The HMO gives a Provider Directory to each new enrollee. 

Service area:  geographic region an HMO serves.   

Benefits package (= “covered services”):  Medicaid services which state-contracted HMOs are responsible to provide.  Include:

Other services, such as mental health and substance abuse for non-DDD clients, physical, occupational, and speech therapies, some transportation, intermediate care facilities for children with developmental disabilities, medical day care, and nursing home care continue to be covered by Medicaid, but under the fee for service payment system, not under the managed care program.  *See also “fee-for-service” under “Payment” section, and “carve-out services” under “Services” section. 

Care Management: steps to assure that an enrollee receives needed services in a timely manner.  Emphasizes prevention, continuity of care, and coordination of care. Advocates for and links enrollees to services across providers and settings. 

Individual Health Care Plan (IHCP): plan of care for HMO enrollees with special needs who qualify for a higher level of care management based on a Complex Needs Assessment.  IHCPs specify goals, needed medical services & relevant support services, specialized transportation & communication, appropriate outcomes, barriers to effective outcomes, and timelines. IHCP is developed by the Care Manager with enrollee and Primary Care Physician (PCP) input; is updated as needs arise or change.

Member handbook:  the HMO booklet each new enrollee receives, with facts about how the HMO works, how to solve problems, and what the member’s rights and responsibilities are regarding the HMO. 

Member services: HMO department you can contact with questions, problems, and/or complaints.  Toll-free, open Monday to Friday during working hours.  HMOs also have toll-free 24-hour hotline numbers to handle urgent calls or emergencies. 

CHILDREN WITH SPECIAL HEALTH CARE NEEDS

Children with special health care needs: children who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type and amount beyond that required for children generally. 

Disability in Children: physical, or mental impairment(s) in persons under age 18 resulting in marked and severe functional limitations that limit the child’s ability to function independently, appropriately and effectively in an age-appropriate manner; and which can be expected to result in death or which can be expected to last 12 months or longer. 

“PEOPLE”

Beneficiary: person eligible to receive services in the NJ Medicaid program.  Eligibility for Medicaid determined by County Welfare Agency (CWA) or Supplemental Security Income (SSI). 

Authorized Person: the person who makes enrollment and other health-care decisions for the beneficiary.  May be the beneficiary, a parent or guardian, or someone with the power of attorney to make those decisions for the beneficiary. 

Enrollee (or member):  person enrolled in any of the NJ Medicaid managed care HMOs. 

Provider:  any physician, hospital, facility, or other health care professional who is licensed or authorized to provide health care services in the state.  

Participating Provider: provider that has a contract with the HMO to provide services. 

Non-participating provider (or non-network provider): a service provider that does not have a contract with the HMO.  Prior authorization from the HMO must be obtained in order for the HMO to pay for services of a non-participating provider. 

Primary Care Provider (PCP):  health care professional responsible under managed care for providing basic medical care, referrals to specialty providers, and continuity of patient care.  Sometimes referred to as a “gatekeeper.”

PCPs may be MDs in family practice or pediatrics, or doctors of osteopathy (DO), or certain other licensed medical practitioners such as Certified Nurse Practitioners (CNP), Clinical Nurse Specialists (CNS), or Physicians Assistants (PA).  A specialist may serve as a PCP.  The practitioner must be able and willing to carry out all PCP responsibilities in accordance with the contract. 

Specialist:  a provider who concentrates on a particular health condition or age group.  Under managed care, specialist care requires a referral from the PCP. 

Care Manager:  registered nurse or social worker employed by or under contract to the HMO who is responsible for collaborating with enrollees with complex needs to develop and monitor Individual Health Care Plan.  Care Managers help coordinate all needed services, including those received outside the HMO, such as PT, OT, Speech Therapy, and transportation. 

Health Benefits Coordinator (HBC):  individual who can provide information and assistance to persons eligible for Medicaid managed care on how to choose, enroll in, transfer from, or problem-solve about an HMO plan.  Enrollment in the Medicaid managed care HMO is through the HBC.  The HBC can make home visits.  Employed by the organization under contract to the State to provide these services (called Maximus); not employed by the HMO. 

PAYMENT

Fee-For-Service (FFS):  the traditional method of payment under which providers bill Medicaid directly for services.  Most Medicaid managed care HMO enrollees still obtain some services outside the HMO that are billed on a fee-for-service basis (e.g., physical, occupational, and speech therapies, and some home health care; and mental health/substance abuse services for people who are not clients of the New Jersey Department of Developmental Disabilities). 

Medicaid recipients who follow the correct procedures for their HMOs should never receive a bill.  If they do, they should immediately take it to their care manager for resolution.

BENEFITS LIMITS

Referral: approval for an enrollee to receive services from a specialist or other health care services.  The PCP commonly provides the referral.   Without a referral, the HMO may refuse to pay for the services. 

Standing Referral: your PCP can issue a referral for a number of visits to frequently-seen specialists or other providers. 

Prior Authorization (= “preauthorization” or “preapproval”):  HMO medical or dental review process that gives a provider permission to proceed with a course of treatment.  Some services will be paid for only when there has been prior authorization from the HMO. 

Formulary List (or Formulary): an approved list of prescription medications and their uses that each HMO develops.  Each HMO has its own formulary.  Only drugs appearing in the individual HMO’s formulary will be paid for by the HMO. 

If an enrollee’s medication is not in the formulary, the PCP may be able to prescribe an equally effective medication that is in the formulary.  In order for the HMO to pay for a non-formulary medication, the PCP must certify the medical necessity of the medication and the HMO must approve the PCP’s request to go outside the formulary.  (There are some prescription medications that are paid for by Medicaid on a fee-for-service basis outside the HMO, including: clozapine, respiridone, olanzapine, ziprasidone, quetiapine, and methadone.  The HMO review procedure is not necessary for these medications.) 

Excluded services (also called “carve-out” services): see under next section, “Services.” 

SERVICES

Medically-necessary Services:  services that are consistent with the enrollee’s diagnosis, meet accepted standards of good medical practice, and can be safely provided.  HMO clinicians may review a provider’s proposed course of treatment to determine medical necessity.

In addition for children, medically necessary includes an additional requirement that the services are appropriate for the age & health status of the child, that the service will aid overall physical and mental growth and development and/or the service will assist in achieving or maintaining functional capacity. 

Durable Medical Equipment: equipment, including assistive technology, which can be used repeatedly, is used to service a health or functional purpose, is ordered by a qualified practitioner, and is appropriate for home, school, or community use. 

Diagnostic Services: medical procedures to identify illness, injury, or other health condition(s) of an enrollee. 

EPSDT (Early and Periodic Screening, Diagnosis and Treatment):  program that covers screening & diagnostic services to determine physical & mental conditions in children under 21; and treatment to correct or reduce the effects of conditions found. (Under federally-mandated regulations found in Title XIX of the Social Security Act). 

Out-of-area services:  services covered under the benefits package included in the Medicaid contract which are provided to enrollees outside of the defined service area. 

Excluded services: services not provided by the HMO but covered under Medicaid fee-for-service program.  Also called

“Carve-Out services,” or “carve outs” they include:

• mental health services, unless beneficiary is a non-institutionalized client of NJ Division of Developmental Disabilities (DDD);

• certain prescription medications;

• personal care assistant services;

• therapies, including physical, occupational, and speech

• some blood factors.

LEVELS OF CARE

Routine Care: treatment of a condition that would not worsen if not treated within 24 hours or could be treated in a less urgent setting such as a doctor’s office or by the patient. 

Urgent Care:  treatment of a condition that is not life-threatening, but which the PCP decides requires treatment within 24 hours to prevent deterioration.  Call the PCP or the HMO’s 24-hour phone line to arrange for urgent care.

· Do not use the emergency room for routine or even urgent care; it will not be paid for. 

Emergency Care: covered inpatient and outpatient services furnished by any qualified provider that are necessary to evaluate or stabilize an emergency medical condition

Emergency Medical Condition:  a medical condition with symptoms of such severity (including pain) that a prudent layperson could reasonably expect it to threaten life or to significantly impair health

Prudent Layperson: any person without medical training who possesses an average knowledge of medicine and health

Call 911 or go to the nearest emergency room for an emergency medical condition.

ENROLLMENT & ASSIGNMENT

Enrollment: process by which a Medicaid-eligible individual applies to use an HMO instead of standard Medicaid benefits, and their application is approved

Mandatory enrollment: a Medicaid-eligible person is required to enroll in an HMO, unless otherwise exempted, to receive services in the benefits package.

Voluntary enrollment:  process by which a Medicaid-eligible person voluntarily enrolls in an HMO 

Exceptions:  Medicaid/Medicare dually eligible individuals may enroll in Medicaid managed care, but for the time being are not required to do so. 

Exemption: some Medicaid beneficiaries with complex medical or mental health needs who have providers who are not in any Medicaid HMO network may be allowed to continue to receive services from them (i.e., will not have to enroll in Medicaid managed care).  Exemptions must be applied for through the HBC.  Each request for exemption is reviewed, and if denied, may be appealed through Medicaid Fair Hearing Process.   

Enrollment Period:  time when you decide which HMO you will choose  

Disenrollment: removal of an enrollee from participation in a particular HMO, but not from Medicaid 

Automatic Assignment or “Auto-Assignment”: process whereby the State assigns Medicaid beneficiaries to an HMO when the  beneficiaries fail to choose their own

PCP Assignment: process whereby Medicaid beneficiaries enrolled in a Medicaid HMO receive a Primary Care Provider (PCP) when they do not choose their own 

Transfer:  an enrollee’s change from enrollment in one HMO to a different HMO 

PROBLEM RESOLUTION

Complaint: protest by an enrollee about the conduct of the HMO, or an act or failure to act by the HMO, or any other matter in which an enrollee feels aggrieved by the HMO, that is communicated to the HMO and could be resolved by the HMO within the day (24 hours) of receipt. 

Grievance:  any complaint submitted in writing or orally which could not be resolved within the same day (24 hours) of receipt 

Complaint or Grievance Procedure:  process within the HMO for consumers or providers to use to deal with disagreements about services, procedures, or billing. 

Explanation:  medical reason for a negative decision (and the HMO policy language that allows the decision) 

Contested Claim: claim that is denied because the claim is ineligible, the information is incomplete or incorrect, the amount claimed is in dispute, or the claim requires special treatment. 

Appeal:  a formal telephone or written request to a health plan to change a decision based on medical necessity 

Fair Hearing: the process by which Medicaid beneficiaries use their legal right to appeal negative decisions from their HMO in front of an administrative law judge. 

Independent Utilization Review Organization (IURO): the independent body to whom the New Jersey Department of Health and Senior Services, Office of Managed Care, refers appeals that could not be resolved within the HMO process.  The IURO has no ties to the HMO.