| SNiP Tips
Benefits
What benefits do HIV SNPs offer?
People in HIV SNPs get all the same services as traditional Medicaid. Most of these
services, like primary care visits, are paid for by the plan and have to come from network
providers.
How can my client get specialty care?
When the PCP can't give care that the enrollee needs or when your client wants to
see a specialist, the PCP will give your client a referral. A referral
is a piece of paper with information including the name of the specialist. These specialists
are usually network providers, but if the plan does not have an appropriate provider in the
network, the plan has to pay for a non-network specialist.
After getting a referral, enrollees are supposed to get appointments with specialists
within 4 to 6 weeks. They can contact member services if they have trouble getting an
appointment.
| SNiP Tip: Advise your client to hold onto
the referral even after the appointment with the specialist in
case there is a disagreement with the plan later.
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Enrollees who need lots of care from specialists can get a standing referral.
This will allow them to see the specialist for a certain number of visits or a certain length
of time without getting a new referral from the PCP each time.
An enrollee with a chronic illness in addition to their HIV can get a
special referral that will make a non-HIV specialist the coordinator of the enrollee's primary
and specialty care. Enrollees can call the HIV SNP's member services to find out how to get
standing and special referrals.
How can my client get emergency care?
People in HIV SNPs can get emergency care from any provider inside
or outside the network without a referral or prior approval. An
emergency is a medical or behavioral condition that a person with
an average knowledge of health thinks will cause serious harm without
care right away. Even if the situation does not turn out to be an
emergency, the plan has to pay for the care if it was reasonable
for the person to think that it was an emergency. This is called
the prudent layperson standard. This applies to
both medical and behavioral emergencies.
| SNiP Tip: Sometimes your client will
need "urgent care" which is different from "emergency care."
Urgent care is for non-emergency conditions that will harm
your client's health if not treated within twenty-four hours.
For example, PCP (pneumocystis carinnii pneumonia) is a
condition that requires urgent care to prevent rapid and
life-threatening progression of the disease. If your client
needs urgent care, have her call the primary care provider
right away. An appointment should be offered the same or
the next day.
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What other services can my client get outside the network?
There are some services that HIV SNP enrollees can get from any Medicaid provider
using their Medicaid card. A referral from the PCP or approval from the plan is not
necessary to access these services. These include prescription drugs, treatment for
tuberculosis, some mental health and substance abuse services, and family planning
and reproductive health care.
How can my client get family planning and reproductive health services?
Enrollees can get family planning and reproductive health services from any Medicaid
provider, whether or not the provider is a part of the plan's network. They don't
need a referral from the PCP or approval from the plan. If the provider is
outside of the network, your client will need to show her Medicaid card. The plan has
to tell all enrollees of childbearing age of this right and has to give them lists of
in- and out-of-network reproductive health and family planning providers.
Family planning and reproductive health services include:
- Birth control
- Emergency contraception
- Pregnancy testing and counseling
- Abortion
- Pap smears
- Pelvic and breast exams
- STD testing and treatment
- HIV testing and counseling
These services include all necessary education and counseling. When necessary,
family planning services include screening, diagnosis, and treatment for sexually
transmissible diseases, sterilization services, and screening for pregnancy.
| SNiP Tip: Minors have the same
right to get family planning services in HIV SNPs as
adults. The plan has to keep all information about
family planning confidential for both adult and minor
enrollees. Tell your teenage clients that their parents
or guardians won't be told if they get family planning
services.
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How Can My Client Get Mental Health and Substance Abuse Services?
Enrollees can self-refer for one mental health assessment from a
network provider in any calendar year. This means they can get this assessment without
a referral or prior authorization. Enrollees can also self-refer for one chemical
dependence assessment for inpatient detoxification, inpatient rehabilitation or
outpatient detoxification services. All enrollees will get a list of participating
mental health and substance abuse providers from the plan, including a list of
children's mental health specialists. Please see Appendix VI for a complete listing
of mental health and substance abuse services.
Enrollees who want a chemical dependence assessment for any alcohol and/or
substance abuse outpatient treatment services, except outpatient detoxification
services, must use their Medicaid benefit card to go to any provider that takes
Medicaid.
| SNiP Tip: The People who need on-going
mental health and/or substance abuse services can get
help from the HIV SNP's case management system. In some
areas, HIV care and substance abuse care will be available
in the same place. Your clients can ask their case managers
to help them find this kind of site if they need these
services.
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