Managed Care and You

It used to be that if you had Medical Assistance in Maryland, you went to any doctor (or other provider, pharmacy, etc.) and Medical Assistance paid for the services.

Today, most people with Maryland Medical Assistance or the Maryland Children's Health Program must get their health care through a managed care organization (MCO) under HealthChoice.  The term “managed care” actually covers a lot of different kinds of health plans, but most managed care plans have certain things in common.  With many managed care health plans, you usually have to go to one of the providers on the health plan’s list.  Only the doctors and other providers on that list have agreed to be part of that plan’s network. 

Over the past few years, health care has become more expensive.  Managed care is supposed to keep down the costs of health care by cutting out “unnecessary” services.  Sometimes you and your plan may disagree as to what is a necessary service.  If you have this disagreement, you should file a complaint or grievance with your MCO.  Please see the page on this web site When You Have a Concern or Complaint for more information.

When you sign up for a managed care organization, the MCO will often call you a “member” of the plan.

What is a “Primary Care Provider?”

Under your MCO, you will have a “primary care provider” or PCP  This is the doctor, nurse practitioner, or physician’s assistant to whom you often have to go first when you need medical help.  Usually, you cannot decide on your own to go to a specialist.  If you need a specialist, your primary care provider usually has to refer you to the specialist.  If you just go on your own without the doctor’s referral, the health plan may not pay for the specialist’s services.

How do I choose the right MCO for me and my children?

Be the Smart Consumer:  Make a checklist of the things that are important to you in a MCO.  This list will be different for each person, and it may be different for each family member.  Your list may include things like:

• Doctor offices are close by my home or work.

• Specialists that I need are included in the MCO's network.

• The doctor speaks my language and the staff understands my culture.

• The MCO has a good record of caring for people with diabetes or other health problems.

• My current doctor, specialists, pharmacy, durable medical equipment supplier (wheelchairs, etc.), disposable medical supplier (Attends, feeding tubes and supplies, etc.), and dentist are in the MCO.

• The plan pays for medicine that I am taking.

• I can get a clinic’s or doctor's help over the phone.

• Emergency services are available nearby and quickly.

• I can continue my treatments.

• I can use the hospital that I prefer.

   

  After you have made your list, pick out the top ten things in your list and put these in order with the most important ones first.

Try to obtain as much quality information as you can about the MCOs you are considering joining.   The Delmarva Foundation conducts an annual review of MCO quality.  Call the Department of Health and Mental Hygiene (DHMH) at 410-767-5800 for a copy of the latest report.  As you look at quality information like diabetes care, asthma care, and surveys, keep this list next to you to help you stay focused on the things that are important to you.

How do I choose the right health care provider?

If you already have a doctor that you like, you probably want to keep that doctor, if possible.  Call up the doctor’s office and ask if the doctor accepts the MCO that you are looking at.  If the doctor is not in that MCO, ask if she would consider joining that plan’s network.  If not, ask the doctor which MCOs she contracts with..

Look at where the plan has providers.  Check the provider directory sent in your enrollment packet. This information is also available on the Internet on the 

DHMH website.  Whether you look at the information on the website or in the directory, the information may be out of date.  You should call the plan to confirm the information and check with the doctor to confirm that she belongs to the plan.

Does the MCO have providers or medical groups that are conveniently located for you?  If you see a doctor or medical group that interests you, call the office and confirm that they accept the MCO and that they are accepting new patients.

Be the Smart Consumer:  Do you need to change doctors?  Many people with several health care needs find that some of their doctors are in their new MCO, but some others are not.  

If you change doctors, make sure that your new doctor gets your medical files from your previous doctor so that the new doctor can give you the best possible care.

If you have to change doctors, ask the new doctor for an interview.  You can meet with the doctor to see if you feel comfortable with her.  Prepare a list of questions before you have the interview.  Do you feel that this new doctor will give you the kind of care that you need?

What if I need on-going care from a specialist?

Look through the MCOs provider list.  Is your specialist on the list of doctors? If not, and staying with the same specialist is important to you, is she with another MCO you would consider joining?  If you are willing to change specialists, do you see a doctor listed with the specialty that you need?   Is there a specialist conveniently located near you? 

If you are the parent of a child with special needs, you will want to be sure that the plan has doctors that are both pediatricians and specialists in the area of your child’s special need.

Remember, you will need a referral from your primary care provider for most specialty services.

What particular things might families with children with special needs look for in an MCO?

Get a sense if the care provided to children with special needs is family-centered.  Does the plan or the medical group address the "whole child" and include parents in decision-making?  Do they offer education and support for self-care in the home?

What should you expect from your child’s primary care doctor and office staff?  The American Academy of Pediatrics (AAP) supports the medical home concept for CSHCN.  The medical home offers families a central location where information is located and care is coordinated for the child with special health care needs.  Families should also expect help with transitions to school and adult services and linkage to needed support, educational, and community resources.  The care provided should be family-centered and culturally-competent with concern for the child and family utmost.

Not all primary care providers provide this kind of attention and detail to the

families of children with special health care needs, but the medical home concept

can serve as a model for families looking for the best care.

For more information about the Medical Home visit the AAP web site at http://www.aap.org/advocacy/medhome/ResourcesMaterials.htm

Many families find case managers very helpful for coordinating a child’s care when the child needs a variety of health care services.  All of HealthChoice's MCOs offer case management services for children with special health care needs and other special populations including adults with disabilities, and adults with HIV/AIDS.  Call the MCO's Special Needs Coordinator for more information about how they can help. 

How do I choose a hospital?

When you are choosing your doctor, the provider list will often tell you at which hospitals that doctor has admitting privileges.  That is, each doctor will be associated with certain hospitals where the doctor’s patients will get most of their hospital care.  With some MCOs, you may be limited to one or two hospitals.

Most of us probably do not pay much attention to the choice of hospital.  However, if you regularly need hospital services or if you are going to need hospital care, like an operation, sometime in the near future, you should pay attention to your choice of hospitals.

How can I find out if the MCO will pay for the prescriptions that I need?

Ask for a copy of the MCO's drug formulary.  The formulary is a list of all of the drugs that a MCO will pay for.

Look at the formulary to see if all of the medications that you regularly take are on the formulary.  Are they all listed?  If they are not all listed, does the formulary explain how you may be able to get drugs that are not listed on the formulary?  If your medication is not listed, and you cannot tell whether the MCO will cover the medication anyway, you should check with the MCO to find out how you can get coverage for that medication.

Formularies change from time to time.  You may want to ask your health plan what happens if your medication is later dropped from the formulary.  Is there a way to continue to get the medication?

If your health plan refuses to pay for a medication that your doctor says that you must take, be sure to file a complaint or grievance.

How do I know whether the doctor's offices are accessible for me?

If you need your health care providers’ offices to be physically accessible, such as for a wheelchair, you should call the providers’ offices to ask.  By federal and Maryland law, health providers’ offices, like any public accommodations, must be accessible to people with mobility impairments. 

Be the Smart Consumer:  If the offices are not physically accessible, then you should file a grievance and you may file a complaint with a federal or state civil rights office.  Don’t be afraid to assert your civil right to accessible offices!

Will the doctor understand my culture and speak my language?

When you are choosing a doctor, the MCO's provider list will list which doctors offer services in languages other than English.  Look for a medical office that speaks your language.

Of course, just because a medical office is listed as providing services in a particular language, it does not mean that you will get good services in that language.  You should be able to get all written notices in your language.  You should never have to sign a consent form without understanding in your own language what you are consenting to.  

Likewise, you should also expect medical services that are culturally appropriate.  If you are a woman and for cultural reasons you may not be examined by a male doctor, you have a right to insist that you be examined by a female doctor instead.  You may want to see whether your health plan trains people in cultural competency.  You have the right to have your cultural needs respected.

Be the Smart Consumer:  If your health care provider does not offer services in your language, demand that the health plan allow you to change providers.  It is your right under federal law to receive medical services in a language that you understand.  You must get professional and correct translations and interpretations.

Click here for our list of Terms to Know. 

Where can I find more information about HealthChoice and MCOs?

Check our HealthChoice Basics page and the DHMH website for more information about HealthChoice and other Maryland medical programs.