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Voluntary Managed Care
WHAT IS THE VOLUNTARY MANAGED CARE PROGRAM?
The Voluntary Managed Care Program is offered in some Pennsylvania
counties where HealthChoices has not been implemented. You may go
to the Statewide
Managed Care Map to see the status of the county where
you live, and get information to contact any of the approved Voluntary
Program MCOs in your county.
If you live in a county with a Voluntary Managed Care Program and
you are on MA (have an ACCESS card), you have a choice of how you
receive your Medical Assistance (MA) benefits. You have two options:
- Stay on the regular MA ACCESS program (also called "Fee
for Service" or "FFS") or Family Care Network,
if under 21 years of age, or
- Join one of the MA managed care health plans (called MCOs) available
in your county.
DO I NEED TO CHOOSE AN MCO TO RECEIVE MY MEDICAL ASSISTANCE
COVERAGE?
You are NOT REQUIRED to choose an MCO in order to receive MA benefits
if you live in a county with the choice of the Voluntary Managed
Care Program. If you are on MA (have an ACCESS card), you can choose
to stay on the regular MA ACCESS program (also called "Fee
For Service" or "FFS") or Family Care Network (if
under 21 years of age). You may also choose to get your MA through
one of the MCOs available in your county. This information is to
help you decide what is better for you and your family.
Where are the MCOs allowed to market?
DPW allows MCOs to market at the following locations:
- County Assistance Offices (CAOs)
- Doctors’ offices and clinics
- Some health fairs and community events (which DPW must approve
in advance)
- Other sites (like WIC offices) that DPW has approved
Are there limits on how the MCOs market?
Yes. MCOs are not allowed to:
- Come to a MA consumer’s home unless the consumer specifically
requests it.
- Telephone a consumer at home unless the consumer requests it.
- Send any unsolicited direct mail to consumers.
- Approach consumers on the street.
- Offer cash, coupons, or certificates of value to get consumers
to enroll.
- Misrepresent who they are, available services, or benefits provided
If you are aware of any of these actions taking place, please call
the MA Help Line at 1-800-692-7462 and report the
details.
THINGS TO THINK ABOUT BEFORE DECIDING WHETHER TO JOIN AN
MCO
How is joining an MCO different from how I receive MA now?
There are many differences. One is that when you join an MCO, you
must choose a Primary Care Physician (PCP), who will provide most
of your medical care. If you need specialty care, the PCP must refer
you to other medical providers (specialists). There are
exceptions:
- dental care,
- vision care,
- family planning,
- routine OB-GYN care and emergency care do not require a referral.
- A second difference is that when you join an MCO you can ONLY
visit medical providers that are in the MCO network. Each MCO
has a network made up of doctors, dentists, pharmacies, hospitals,
and other medical providers/specialists. Before you join an MCO,
you should check to make sure your PCP, your specialist(s), your
hospital and any other providers that are important to you are
in the MCO’s network.
What services are covered by MCOs?
Each MCO must provide the medically necessary services covered
by regular MA with your ACCESS card. Some MCOs may offer extra benefits
or services that you do not get now. If you are receiving ongoing
medical treatment now and decide to join an MCO, the MCO will need
to review whether you can keep receiving that medical treatment.
What about health care for my kids?
All the MCOs you can choose from provide children under 21 with
all medically necessary services. Children can also get hearing,
dental, and vision screens as well as regular immunizations (shots).
What about family planning services?
Family planning helps you to choose when to have children. Available
services include birth control, pregnancy tests, and tubal ligations
(tying the tubes). You can also get other services like pap smears,
treatment for sexually transmitted diseases, and HIV testing and
counseling. If you join an MCO, you may still get all these services
from the clinic or doctor of your choice without being referred
by your PCP.
How will I get mental health and drug and alcohol treatment?
These are also called behavioral
health services. If you choose to join an MCO you will continue
to get these services with your ACCESS card.
Can I change my MCO or my PCP?
You may change PCPs at any time for any reason. You must call the
MCO’s member services number and request a change in PCP.
You can also change MCOs at any time for any reason. You can change
your MCO by completing what is called a "disenrollment form."
After the signed form is fully processed, you may then choose to
join another MCO or remain under regular MA FFS.
What can I do if I am not getting the services I need or
if I am having problems with my MCO?
You can file a complaint or a grievance with your MCO. If your
health is in danger, you can file an emergency grievance that the
MCO must respond to within 48 hours. You can also ask for a fair
hearing from DPW if you have been denied services.
If I join an MCO, can I change my mind and go back to the
regular FFS program (or the Family Care Program, if under 21)?
This is called "disenrollment". Each MCO has its own
disenrollment form that you must sign and return to the MCO. There
are two ways to disenroll:
- Call the MCO and request a disenrollment form. When the form
comes, fill it out and sign it, and mail or fax it back to the
MCO; or
- Go to the County Assistance Office when the MCO is marketing
there and ask them for a disenrollment form (they are required
to carry the forms at all times), fill it out and sign it, and
mail or fax it back to the MCO.
How long does it take to be disenrolled from an MCO?
If you mail the form, you should call the MCO back in a week or
two to make sure the form has been received. Once the MCO gets the
disenrollment form they are required to quickly turn the form in
to DPW to process. You should be disenrolled within 30-45 days from
when the MCO receives your signed disenrollment form.
Where can I go for help with questions or problems about
Voluntary Managed Care?
For free legal advice and assistance call the Pennsylvania Health
Law Project at (800) 274-3258 or (412) 434-5779.
Last modified on: December 10, 2004
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