In the past few years, you may have heard conversations about managed care, and states moving their Fee for Service system to managed care. If you live in Texas, Florida, Kansas, Tennessee, or New Hampshire, you have lived through this transition. There are probably other states that have some sort of managed care for children in foster care. I am sure there are also varying opinions of how well it works, or what it really is supposed to do.
Because I work for a behavioral health managed care organization, I’ve witnessed many transitions, and have certainly formed opinions about what works well, and what did not. But I think it is important to step back, and explain why this occurs in the first place.
Children in foster care receive health care services, such as physical health, dental, mental health and optical services through each state’s Medicaid program. Historically, these services have been provided on a Fee for Service basis, which means, that one can take a child to any Medicaid provider, at any time. What the Fee for Service system lacked, however, is coordination of care.
This can mean the transference of records from one doctor to the next, coordination between a primary care doctor and a psychiatrist, and a historical record over time of what these children access as they move from place to place.
As an adoptive parent, who adopted all three of my children before managed care, it was a challenge pulling together their health care records, especially a timeline of therapeutic interventions.
There was no place for me to go to gather info on who my children’s therapists were, what the focus of therapy was, what medications they had been on before, etc. I had to ask each child if they knew if they had chicken pox, and worse, there was not a consistent record of immunizations – sometimes meaning my kids were immunized twice, or more!
Thus, state Medicaid agencies, working alongside the child welfare system, have decided to move to managed care organizations to help coordinate the extensive Medicaid system. A managed care organization has the ability to bring care coordination teams in, as well as technological systems to help create the health records that track services statewide for each child, regardless of how often the child moves. A managed care organizations job is to ‘manage’ the care.
The state essentially contracts with a managed care organization to manage the Medicaid funds for this population.
The state defines what services are covered, or not covered, and has systems in place to assure that managed care organizations review requests for services to make sure they are in line with medical necessity – meaning, the child needs the services and it is medically appropriate.
There is a lot more to managed care, such as contracting with a network of providers to serve the children, and paying the claims submitted by these providers. There are also call centers to answer questions and provider referrals. Managing care also means having a team of care managers, who help coordinate the services the children receive. Care coordination can also involve a care management component, where this team is involved with case workers and foster parents to learn more about the child, help problem solve and identify alternative or unique services, such as step-down services from inpatient hospitalization.
If you have the opportunity to be involved in planning for the transition to managed care, there are a variety of things you should highlight, but most important is to seek a managed care partner that has expertise working with children in foster care.
What does this mean? It means, for example, a company that:
1) understands the difference between behaviors and mental illness
2) understands trauma
3) understands placement issues
4) designs programs to assist with special populations, such as medically fragile children
5) has physicians in its network available that understand the dynamics of abuse and neglect
6) has therapists that are experts in abuse, neglect, permanency, trauma, sexual abuse, adoption
7) has clinicians skilled in assessments targeting the unique needs of children in foster care
Bottom line, look for a partner.
Now, if you find yourself involved with managed care after the fact, what can you do to become more familiar?
1) Reach out and ask about foster parent orientation
2) Ask about trainings that are offered, such as trainings on Trauma and behavior interventions
3) When the managed care organization calls to gather health information, share what you know so that a record can be started, and appropriate care can be provided.
4) Ask questions - do not expect that your child placing agency, or your local department of children and families has all of the answers, they are probably learning as you are. The best approach, whether you are a foster parent, or a case worker, is to call and ask to speak to the program director, or a care manager. Ask what special programs they have, and how the program works.
5) Give it a chance – change is a challenge for everyone
Also know, that the managed care organization’s staff is learning as you are, adapting to the local nuances of the community, learning about the challenges faced and, most importantly, should want to get to know you. Invite them to meetings, ask the staff to come and share. It is through working together and getting to know each that these programs can evolve and better serve the children.
Not every organization and company is created equal. Talk to your state, and share your needs, concerns and expectations.
Owner/Editor - Chris Chmielewski