Medicaid Managed Care Information
CARE MANAGEMENT AND THE MEDICAID HMOS
Whenever a person with special needs, who is enrolled in a Medicaid HMO, has a problem obtaining necessary medical or dental services from the HMO, the first
person to call is the care manager.
The following phone numbers can be used to contact the care management department at each of the Medicaid HMOs:
AmeriChoice Developmental Disabilities Health Alliance (DDHA) 1-877-334-2462
Amerigroup J anet Pizzelanti, Care Management Supervisor (732) 452-6044
HealthNet Call customer service with Member ID and phone #. Advise that you need a care manager to call back (800) 555-2604
Horizon Mercy Dial Care Coordination Unit using 800 #. Press #2 at the first prompt, then press #1 to reach a CCU team member. (800)
682-9094
University Health Plan Developmental Disabilities Health Alliance (DDHA)
1-877-334-2462
NOTE FOR URGENT PROBLEMS: If you place a call to a Medicaid HMO care manager and you have an urgent problem, please indicate the urgency of
the situation to the person who answers your call or in your voice mail message. If your call is not returned within the same day, you can also call the Member Services Department (that phone number is on the
HMO card) and ask to speak with a supervisor; indicate that you have an urgent problem and you need to be connected to a care manager quickly.
The Arc of New Jersey is tracking HMO enrollees' positive and negative experiences with care management, and we may be able to intervene if problems
arise. Please call 732-246-2525, ext. 28 if you want to provide feedback on care management issues.
Other phone numbers that you can call for Medicaid HMO problems are:
The Medicaid Hotline: 1-800-356-1561
NJ Protection & Advocacy Health Care Consumer Assistance Program 1-866-486-5456
Please note: The following groups of Medicaid beneficiaries are not required to enroll in a Medicaid HMO:
Consumers who also receive Medicare are not required to enroll in a Medicaid HMO. (However, they may enroll in an HMO if they choose to do so.)
Consumers who have applied for an exemption will not be auto-assigned, pending the outcome of the exemption request. (If the exemption request is denied,
the consumer will be given the opportunity to file an appeal, and if that is denied there is an opportunity to choose an HMO.) Forms to request an exemption are available from the health benefits coordinator at
1-800-701 -0710.
Consumers who are already enrolled in a private HMO that does not have a contract with Medicaid will not need to enroll in a Medicaid HMO. (Please note:
Consumers who also have private fee-for -service insurance or who have a PPO rather than private HMO insurance ARE required to select a Medicaid HMO.)
Individuals in the following Home and Community-based Waiver programs are excluded from enrollment in Medicaid managed care:
- Model Waivers I, II, and III
- Enhanced Community Options Waiver
- AIDS Community Care Alternative Program (ACCAP)
- Community Care Program for Elderly and Disabled (CCPED)
- ABC Waiver for Children
- Traumatic Brain Injury (TBI)
- DYFS code 65 children.
Consumers living in a developmental center, psychiatric institution, or nursing home are excluded from managed care.
Consumers who are living in out-of-state placements are excluded from New Jersey's Medicaid managed care program.
Exemption Policy
A small number of individuals may be eligible for an exemption from Medicaid managed care, if they have complex medical or mental health problems, and
have a fee-for-service network of outstanding health care providers that cannot be transferred into one of the Medicaid HMOs. Exemption requests will be reviewed on a case-by-case basis by staff from the
Division of Medical Assistance and Health Services (DMAHS). For further information on how to request an exemption, contact a Health Benefits Coordinator to request an exemption form by calling
1-800-701-0710. If an exemption request is denied, the individual (or the caregiver) has the right to file an appeal.
HMO Enrollment Process
Some computer problems in selecting a PCP (Primary Care Physician) A significant problem has occurred in some recent enrollments of SSI beneficiaries into
Medicaid managed care, in which they have not gotten the PCP they selected on their enrollment form. These SSI beneficiaries wrote the name of their PCP on the enrollment form; however, when the HMO sent
them their enrollment material, the membership card had the name of a different PCP. We have heard about a problem in which some SSI beneficiaries had written their primary doctor's name on the HMO enrollment
form, but when they received their HMO card, they had been assigned to a different primary care physician (PCP). When completing the HMO enrollment form, it is important to include both the first and last name
of the primary doctor and also the doctor's complete address. Some of the mistakes have occurred when there are two or more physicians with the same last name in the same city, and the person completing the
enrollment form did not provide all of the necessary information. If anyone who enrolls in an HMO receives a membership card that does not have the name of the PCP they selected, a call should be made
immediately to the HMO to tell them that there is an error on their card, and the PCP needs to be changed. We have been told that the PCP can be changed very quickly, and should not result in any inconvenience
for the consumer.
The dual eligibles
Persons who are dually eligible for both Medicaid and Medicare will NOT be required to enroll in Medicaid managed care. Anyone in the dual eligible
category who chooses to enroll may do so. The Arc of New Jersey appreciates this policy decision from DHS, believing that our consumers who receive both Medicaid and Medicare will be best served by a flexible
approach.
Health Benefits Coordinators (HBC)
Call toll-free: 1-800-701-0710.
This is the title of the staff who provide assistance to New Jersey's SSI beneficiaries in selecting an HMO.
In deciding which HMO will be best for the individual consumers, lists should be made of the physicians, dentists, hospitals, mental health providers (if
applicable) pharmacies, labs, and suppliers of durable medical equipment that have been providing services to the SSI beneficiaries. The goal is to select an HMO that has as many of the current providers as
possible in its network. Upon request, the health benefits coordinator will tell you the HMOs that these providers are affiliated with. You may also call the providers directly to ask them which HMOs they
belong to. Another alternative is to call the HMOs to ask whether the providers on your list are in their network.
Upon request, health benefits coordinators will meet individually with beneficiaries and their families at their homes to provide information to help in
selecting an HMO and to assist with the necessary paperwork. Call 1-800-701-0710 to make an appointment for a home visit.
To learn more about Medicaid managed care
The Community Health Law Project has prepared a free "Guide to New Jersey Consumer Rights in Managed Health Care." The Law Project can also
provide assistance with problems that arise in the Medicaid, Medicare, or commercial managed care systems. Their toll-free phone number is 888-838-3180. Visit their web site at www.chlp.org
New Jersey Protection and Advocacy (P & A) has established a Health Care Consumer Assistance Program (HCCAP) that provides assistance to New Jersey
Citizens with disabilities who need help navigating the health care and insurance systems – including managed care difficulties. The toll-free phone number is 1-866-486-5456, and the website is
www.managedcarehelpline.org
Visit the Social Security Administration web site at www.socialsecurity.gov
Visit the web site for the NJ Department of Human Services' Division of Medical Assistance and Health Services at
http://www.state.njus/humanservices/dmahs/dhsmed.html
RESOURCES
New Guide for Navigating Medicaid Managed Care
The State's Medicaid office recently released a new publication entitled "Your Guide to Making Medicaid Managed Care Work for You." This
guide was developed, in collaboration with the Boggs Center, to be helpful to persons with developmental disabilities and their caregivers, as well as for persons with other disabling conditions. Medicaid's
Office of Managed Health Care is using this guide as a tool to assist people who receive their health care services from a Medicaid HMO to take a more active and informed role in their health care. The 50-page
guide includes information about how to use managed care, services for people with special health care needs, and how to get assistance, when needed. Printed copies of the guide are limited right now but the
document may be accessed from the following Internet sites:
The Medicaid web page: http://www.state.nj.us/humanservices/dmahs/dhsmed.html;
The Boggs Center: http//rwjms.umdnj.edu/boggscenter/products/pdf/Guide.pdf;
or the Developmental Disabilities Council: www.njddc.org
This information was updated as of August 24, 2007.
Watch this space for continuous updates on Medicaid managed care.
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