| SNiP Tips
How to Get Medical and Social Services
from the HIV SNP
How easy will it be for my client to get medical services?
Providers have to be easy for enrollees to reach. HIV SNP plans should offer
enrollees a choice of three primary care providers not more than 30 minutes away
in urban areas or 30 minutes/30 miles in non-urban areas. The standard is 30
minutes/30 miles for specialty care, hospitals, mental health, lab, and X-ray
providers.
If they want to, enrollees can pick network providers who are outside this
range, if they can pay for and arrange transportation themselves. Otherwise,
non-emergency transportation is covered through the HIV SNP or on a fee-for-service
basis using the client's regular Medicaid card.
HIV SNP plans must have medical services available 24 hours a day, seven days
a week. If your client can't reach his or her PCP (or OB-GYN for pregnant women),
he or she can call the plan's 24-hour toll-free number for services. This number
may be the same or different from the member services line.
Appointments have to be available to enrollees at least as quickly as shown
in the chart in Appendix III, and enrollees shouldn't have to wait more than an
hour at appointments. If your client has been having trouble getting an appointment
or waiting at a provider's office, he or she can file a complaint. (See page 17,
"Solving Problems I: Complaints and Appeals.")
| SNiP Tip: If your client needs help and can't reach his
or her PCP, he or she can call the plan's 24-hour toll-free number at any time
for help getting care. Remember, if it's an emergency your client does not need
to contact the plan before getting care.
|
How does the HIV SNP's case management system help enrollees get
services?
One of the goals of the HIV SNPs is to link medical and social services for
members. This is done by case managers. Your client in an HIV
SNP will be assigned a case manager who will:
- Work with the PCP to coordinate medical care
- Make sure the member knows about plan services
- Figure out what the member needs and develop a care plan
- Check the quality of care that the member gets
- Arrange social services for enrollees
Please see Appendix V for a list of social services that the case manager
can help coordinate. These include many different services like drug treatment,
domestic violence help, and nutritional services. Most of these services are
not given by the HIV SNP itself. These services have been carved-out
of the benefit package the HIV SNP is paid to deliver. Many of them will be
given by community-based organizations that your client may already be connected
with.
| SNiP Tip: Encourage your clients to be very
active in seeking help from their HIV SNP case managers. Some case
managers may call their clients a lot and be very prompt in
coordinating services, but others may be very busy. Your clients can
call their case managers anytime to ask questions or to get help in
coordinating services.
|
What can my client do if a provider leaves the HIV SNP network?
If a health care provider leaves the network, in some cases patients can
decide to continue to see the provider for a temporary period instead of switching
to a new provider right away.
This period lasts for 90 days for most enrollees, starting from the date the
plan tells the enrollee that the provider is leaving the network. If the enrollee
has entered the second trimester of pregnancy, the transitional period will cover
medical care directly related to the delivery for up to 60 days after the birth.
The non-participating provider has to agree to follow the plan's rules and
charge only the amount the plan normally pays.
How can my client switch to a different primary care provider?
HIV SNP enrollees can change their PCP until 30 days after their first
appointment with the PCP without giving an explanation. After thirty days,
enrollees can change their PCP every six months without an explanation. The
plan has to process these requests and tell enrollees the date of change within
45 days. The plan has to switch your client by the first day of the second
month after the request.
Your client can change PCPs anytime for good cause. These
reasons are considered "good cause":
- Your client can't get an appointment with the PCP within the time
limits; (See Appendix III)
- Your client moves, so that the PCP is outside the distance standards;
- Your client and PCP agree that it's in your client's best interests
to switch; or
- Your client's PCP leaves the network or becomes unavailable for
another reason.
The plan has to process these requests within 15 days. If the enrollee
doesn't pick a new PCP within 30 days of one of these events, the plan has
to assign a new PCP.
The plan can also assign a new PCP if:
- The enrollee needs special care for a chronic or acute condition, and
the enrollee and plan agree on a change in PCP;
- The enrollee has behaved disruptively toward the PCP and the
PCP has tried to accommodate the enrollee; or
- The enrollee has taken legal action against the PCP.
In any of these situations, the plan has to first give your client a
chance to pick a new PCP.
Next > >
Contents
© 2003 Gay Men's Health Crisis
|
home 
