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Medicaid Managed Care (HMOs) for DYFS Children
Effective January 1, 2004, all children covered by the DYFS Medicaid program are required to be enrolled in an HMO. This change was made so that children are afforded greater accessibility to providers through these HMOs. As we all know, finding specialists under the old "classic" Medicaid system could really be a challenge! All five of the statewide providers are listed below. Please note that not all providers are operating in all counties. Following are some questions and answers about managed care.
DYFS provides all children entering a resource family home with New Jersey Medicaid, which covers all health-related expenses and treatment received at a hospital or a health care provider who accepts NJ Medicaid.
Fee-for-service is a system for providing health care in which health care providers bill Medicaid directly. In New Jersey, there is a limited number of doctors, dentists and specialists who accept fee-for-service Medicaid.
The Medicaid managed care program is a system for providing health care in a Health Maintenance Organization (HMO). Under managed care, resource parents may choose one of five HMOs for the child in their home. The HMO helps manage the child’s health care and offers all the same benefits as fee-for-service providers, plus:
The paper care you initially receive from the child’s DYFS caseworker when the child is placed in your home allows your child to receive fee-for-service Medicaid until that child is enrolled in a Medicaid HMO. You should use this card in case you have to fill a prescription for child or bring the child to a doctor or hospital. After a month or two of receiving a paper card in the mail, you will eventually receive a permanent, plastic card as your child’s Medicaid ID. If you bring the child to a provider or facility, you must ensure that the provider accepts fee-for-service Medicaid coverage.
You can use the paper card only during the month for which it is issued. The permanent plastic card does not expire as long as the child remains in your home. All DYFS resource parents, including relative caregivers, foster parents, pre-adoptive parents, and Special Home Service Providers, are required to enroll children in their care into a Medicaid HMO within the first 60 days of their placement into the home. If a resource parent does not choose a Medicaid HMO for the child within 60 days, the child will automatically be enrolled into a Medicaid HMO selected by DYFS. (NOTE: When a child is placed in your home, be sure to ask the caseworker if the child is already enrolled in a Medicaid HMO.)
Through managed care, children have greater access to health care providers than through traditional fee-for-service. HMOs provide a comprehensive package of preventive health services that, combined with the full range of Medicaid benefits, allows for the best quality of health care for children.
If at any time, resource parents need assistance in choosing a plan, finding a doctor or dentist, or have questions about managed care, they may contact the HBC at 1-800-701-0710.
How long will it take before my child is enrolled in an HMO?
It generally takes 30 to 45 days for the enrollment to take effect. In the meantime, the child is covered by DYFS fee-for-service Medicaid.
Most children should be enrolled into a Medicaid HMO. There are a few exceptions where enrollment in a Medicaid HMO may not be best for the child. Under these circumstances, resource parents must request an exemption to enrollment by contacting the Office of the Medical Director at 1-609-633-8421. Some reasons to request an exemption include:
The child is in a short-term placement (less than two months).
The child has multiple specialists who do not participate in the same HMO and the resource parent wishes to continue using these specific providers.
You can only use providers and hospitals from the HMO network you choose, unless it is an emergency, or if you get prior authorization from the HMO. If you think your child is having an emergency, call 911 or go to the nearest emergency room! You do not need permission to bring the child to the emergency room in an emergency. If your child has an emergency situation while out of town or out of state, present the child’s HMO and NJ Medicaid ID cards to the facility you bring your child to. You should contact the HMO as soon as possible (within 24 hours) to let them know that the child was seen in an out-of-network facility.
Some other things you should know:
You must always keep both the Medicaid and HMO identification cards with you. Present both cards each time you bring your child to a health care provider or fill a prescription at a pharmacy. Some health service your child receives will be covered under traditional fee-for-service Medicaid. Examples may include psychological counseling or therapy, or physical, occupational and speech therapies. If you are unsure if a service is covered by your child’s Medicaid HMO, you can always contact the HMO’s member service unit directly or your child’s HMO care manager.
All children in resource family care and enrolled in a Medicaid HMO will have an HMO care manager. This means that this person (usually a nurse or social worker) will contact you and ask you about the health needs of the child in your care. This individual will not make visits to your home, but will speak with you over the phone and help answer questions you may have about your child’s health care providers. The HMO care manager will help develop a specific “individual care plan” for the child. The care plan will list any treatment needs and doctors or specialists the child may need to see.
The HMO care manager might also speak with your child’s doctor or health specialist to make sure the child’s health needs are being met and any treatment plans are being followed. The HMO care manager will help you find a dentist, a specialist or other health provider, should your child need one. He/she will help make sure prescriptions for certain medications are approved. They will also help make sure the children in your care are getting the health care services they need.
For example, if you are having trouble finding a specialist, the HMO care manager can provide you with names of specialists who participate in the child’s HMO. If for some reason, a specialist who participates in the child’s HMO cannot be identified, the care manager will work with the child’s PCP to provide the service “out of network.” This means that the HMO will cover the cost of using another doctor.
Yes, you can change your child’s PCP by contacting the HMO’s member services toll-free telephone number directly. Representatives from the HMO member services unit will help you choose a new PCP. It will take about 7 to 10 days to receive your child’s new member ID card with the change. If you need to visit the PCP before you receive the new card, contact the HMO member services unit and they will make the arrangements for you.
AmeriGroup New Jersey, Inc.