Choosing a Managed Care Plan*

In choosing a Managed Care Organization for a child in foster care, social service professionals if given a choice of plans may wish to consider a number of factors. Understanding both the specialized services a child will require, the geographic location of the child’s residence and who will provide primary care are all important matters to bear in mind. A plan’s description of benefits and a list of primary care providers can be found through the plan service representative or, the plan ombudsman. The State Social Services and or Medicaid office may also have information about benefits.

The following list of health care services may be included in Managed Care Organizations.

Therapies/Home Care/Planning Services

Speech and language therapy
Physical therapy
Occupational therapy
Nutrition counseling services
Home nursing services
Personal care attendant
Home health aide
Counseling/mental health services
Genetic services
Hospice
Case Management
Diagnostic testing

Durable Medical Equipment

Ventilator
Suctioning equipment
IV stands and equipment
Air compressors
Feeding pumps
Monitor
Wheelchair
Braces
Casts
Prosthetic devices

Medications and Supplies

Tracheostomy tubes
Gastrostomy tubes
Feeding bags
Specialized dietary products
Dressings
Prescription drugs

Adaptive Equipment

Prone standers
Corner tables
Specialized car seats
Bath aids
Van adaptations
Ramps
Corrective shoes
Eyeglasses
Specialized orthodontics
Prosthetic devices
Communication equipment

Specific questions you may want to ask include:

• Which providers contract with this plan?
  
  
• Does the child currently have a Primary Care Provider?
  • Would the child benefit from staying with the same Provider?
  • Is the provider accessible from where the foster family lives?
  
  
• Are the specialists the child uses available through this plan?
  • Can the child get direct access to the specialists for some services?
  
  
• Where are the hospitals and clinics located? --Are they physically accessible?
  • Does the Primary Care Provider have privileges at nearby hospitals and clinics?
  
  
• Will transportation funds be covered through the managed care organization?
  
  
• Are the specialists and therapists trained in pediatric care?
  
  
• What is the procedure for authorizing urgent or emergency care?
  • What is the procedure for authorizing urgent or emergency care if the child is traveling out of state?
  
  
• Are translation services available to families at the providers offices, or clinics?
  
  
• What coverage is offered for equipment and medical supplies? Where is equipment and supplies available? Who is responsible for repairs and replacements? Who has to approve requests for equipment and supplies?
  
  
• How are prescription drugs covered, and where can they be obtained? Are there any restrictions on the drugs that can be prescribed and paid for?
  
  
• Is there a clinic in the plan that specializes in the child’s diagnosis/disability? Are there classes or informational materials that address parenting and health care issues for our child’s diagnosis/disability?
  
  
• What process or alternatives are available in the event that there is a complaint?
  
  
• How easy is it to change plans if the plan is not meeting the child’s needs or the child’s needs change?
  
  

Choosing a Primary Care Provider

In choosing a primary care provider you are looking for someone who will value you as an expert on your child and acknowledge you as a competent partner. You want your Primary Care Provider to:

• Help you find and continually update the information you need to understand your child’s condition.
• Not withhold or omit any information concerning the severity or extent of your child’s condition. Also, not hesitate to use medical terms when necessary.
• Agree to routinely provide you with copies of any medical records and reports.
• Help you to understand the range of possibilities and tell you the worst and best possible prognosis.
• Acknowledge your sense of urgency by responding quickly to requests for medical information, referrals, etc., so that appropriate services can begin or continue.
• Remind you of your child’s strengths from time to time.
• Collaborate with other professionals providing care for your child.
• Take time to talk with you about your concerns.

Some practical questions you might want to ask before thedoctor has seen your child.

• Do you see children with disabilities in your practice?
• Do you have experience with children who have (child’s disability)__?
• Would you be comfortable working in a medical team situation with other professionals who will be seeing my child?
• Can you schedule extra long appointments?
• Who sees your patients when you are not available?
• Which staff person is responsible for following up pre-authorizations or approvals for specialty care? What is your protocol for getting pre-authorizations?
• Which hospital do you use for patients who require hospitalization or hospital tests?
• What are the facilities of this hospital for children and families like mine? If my child were hospitalized, would I be allowed to stay with him/her?
• How do you handle a child’s fear, discomfort, or pain when preparing him/her for invasive procedures?
• After you’ve examined my child, can you arrange for one of your staff to watch him/her for a few minutes so we can talk alone?
• Would there be any additional charge for any of these arrangements?

*Adapted from Health Care Connections: A Guide for Families of Children with Special Health Care Needs; Produced by Bay Area Family Health Links, CARE, Family Resource Network, Matrix Parent Network & Resource Center, Support for Families of Children with Disabilities

** List is adapted from "PASSPORT: For Children with Special Health Care Needs" from University affiliated Program, Child Development & Rehabilitation Center, Oregon Health Science University.