Case Management � Comparing plans

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					CASE MANAGEMENT                                                                                  6/2008
Center for Independence of the Disabled, NY
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What Kind of Case Management Is Available from Medicaid Managed Care Plans?
All Medicaid managed care plans must offer some type of “case management,” although they have
different ways of providing it, and different ways of deciding which consumers need case managers. A
Medicaid managed care case manager is supposed to coordinate all of the care and services you get from
Medicaid. This includes everything that your health plan provides, such as referrals to specialists and
laboratories, durable medical equipment, home health services, and training for you and your family in
how to deal with your health needs. Case management responsibilities include identification of a health
risk, diagnosis of disease, and development of a treatment plan. If you are in a Medicaid managed care
plan and receive Social Security Income (SSI), the case manager is also responsible for coordinating this
care with services you get from outside your plan’s network, like mental health care.

What can case managers do?
Case management means different things in different plans. Talk to the plan’s membership services
department to find out specifically what case management offers. Among the issues case managers may
help with are:
         Monitoring the care you are receiving from your providers
         Keeping track of your referrals
         Helping you to make and meet your appointments with your doctors
         Seeing that your doctors and specialists are talking to each other about your case
         Making sure that your providers follow-up with your care when necessary
         Arranging specialty care
         Arranging home care
         Arranging community services outside of your plan
         Negotiating different benefits to improve your health condition like education, self-care, or
            arranging for transportation or interpreters
         Getting the durable medical equipment you require

Do All Medicaid Managed Care Plans Offer the Same Kind of Case Management?
No. Some plans use case management to coordinate care for consumers with the most complicated cases
and expensive medical care. Others do mainly what is called “disease management,” where they work
with consumers who have a particular condition. The most common disease management programs
address diabetes, heart disease, high blood pressure, pregnancy, and asthma.

Ideally, case management focuses on individual consumers, looking at all their conditions over a long
period of time. It concentrates on getting the best possible care for consumers, and if it also reduces
costs for the health plan, it does so by eliminating gaps, duplications, and mistakes in care.

Who Is Eligible for Case Management?
 Adults with chronic illnesses and physical or developmental disabilities
 Plan members who have chronic or ongoing mental health service needs
 Children who have or are suspected of having a serious or chronic physical, developmental,
  behavioral, or emotional condition, who also need more health-related services than most other

How Do You Get a Case Manager?
Medicaid managed care plans are required to offer a variety of ways to choose which consumers receive
case management. Certain things may trigger your plan to provide you with a case manager. The plan
may notice your need for case management during a health assessment when you first enroll, for
example when you list diabetes, heart disease, asthma or other chronic conditions. When they review

This information is only for members of Medicaid managed care plans, Family Health Plus, and Child Health Plus B
plans in New York. Commercial managed care plans may have different rules.
CASE MANAGEMENT                                                                                  6/2008
Center for Independence of the Disabled, NY
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your record of using medications and services and see many visits to the emergency room, more than
average hospital stays, or the use of specialty services, your plan may evaluate you for case
Your doctor may recommend that you get a case manager, or you may request one yourself by calling
the member services department. Be prepared to explain why you need a case manager. Send a
written request for a case manager to the health plan’s medical director after your call.

Who is Your Case Manager?
Case managers’ qualifications vary from one health plan to another. Many case managers are nurses or
social workers. Others may have a background in customer service. If you are assigned a case manager,
it helps to know what their background is. Nurses will tend to emphasize your medical care; social
workers will be especially aware of your needs for non-medical services, like housing and transportation;
and customer service experts may focus more on making sure you receive “medically necessary” services.

Pros and Cons of Case Management
In the best situations, case managers can increase the effectiveness of your health care by helping to
coordinate your care with your doctors, and by helping you to coordinate appointments and medications
and to fill out necessary forms related to your care. They can also help you to get the treatment you
need, and arrange transportation, interpreters and other non-medical services. Those knowledgeable
about your disability or condition can also act as an advocate for specialty care and other needs related
to your disability.

Some plans may not have case managers who are familiar with your disability or treatment for your
condition, and the case managers may not have enough training to be able to evaluate your case. This
may be especially true if the case manager does not have a background as a nurse or social worker.

If you have more than one case manager—for example, you also have a child’s Early Intervention
Program coordinator, or a shelter caseworker for a homeless person—the different case managers may
have difficulty coordinating their activities.

If you have issues with your case manager that you cannot solve, you have several options:

   Your doctor may be able to help you if a case manager is reluctant to provide benefits that the doctor
    thinks you need.

   If you are dissatisfied with how your case manager treats you—not returning your phone calls, for
    example—you can contact your health plan’s member services department to file a complaint.

   If you disagree with a decision made by your case manager, make sure you receive the decision in
    writing. You can file a formal complaint or take the next step and appeal the decision.

   When you file a complaint or an appeal, be sure to be specific and include copies of any papers
    you have been given that say the plan refuses to pay for a service or equipment and any evidence
    you have that the services are medically necessary.

This information is only for members of Medicaid managed care plans, Family Health Plus, and Child Health Plus B
plans in New York. Commercial managed care plans may have different rules.
CASE MANAGEMENT                                                                                  6/2008
Center for Independence of the Disabled, NY
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What Are Your Rights to Challenge a Case Manager’s Decision, or Your Plan’s Refusal to Give
You a Case Manager?
If you have Family Health Plus or Medicaid (either fee-for-service or managed care), you can appeal a
denial or reduction of services by requesting a fair hearing.

Make sure you file your request for an appeal within 60 days of the date on your denial or reduction of
services notice.

If you are already getting services and want to avoid having them reduced while you wait for a fair
hearing,  you must request a fair hearing within 10 days of the date on your reduction notice AND ask
to receive “aid-to-continue” while your case is being appealed.

You can bring an advocate and/or witnesses, such as caseworkers, relatives, friends, and/or doctors, to
the hearing to help make your case. (See “The Appeals Process” fact sheet.)

For Additional Information About Your Rights or for Assistance Accessing Health Care:
CIDNY’s Managed Care Consumer Assistance Program: (212) 674-2300 or (212) 674-5619 (TTY)

This information is only for members of Medicaid managed care plans, Family Health Plus, and Child Health Plus B
plans in New York. Commercial managed care plans may have different rules.