Managed care is a comprehensive approach to providing and paying for high quality health care services from educational resources and emergency services to complex inpatient care, all in a cost effective and coordinated system. The most common of managed care plan type are Health Maintenance Organizations (HMOs). Preferred Provider Organizations (PPO’s) are another managed care option available in the Commercial (employer-based) population. If there are options to choose a plan, it is important to do some research prior to selection. The American Academy of Pediatrics has been a leader in helping parents learn to use their managed care plan effectively and has supported early intervention by linking services for children with special needs. Their website, aap.org, can be of great help when determining attributes of a managed care plan to select, as well as in setting expectations for services.

Medicaid is a government program that provides medical assistance for qualified beneficiaries. Most states offer an array of managed care options for Medicaid eligible children with special needs to receive their health care from networks developed by managed care organizations (Hughes et al. 1995). Families of Medicaid-eligible children with special care needs and/or disabilities must make a selection of managed care plans based on the network and benefits provided. If the parent/guardian does not select a primary care provider when they select a plan, the health plan will assign one. Once enrolled the child receives an identification card, a member handbook, provider directory and information on the process called prior authorization.

There is an advantage in having a case manager assigned to a child. The Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) typically has a process in place to automatically assign a for outreach once they have reviewed claim history and found a pattern of services or a specific diagnosis that triggers an alert for extra service.

Tips for Family: Make sure when enrolling a child in a managed care plan, to identify if case management services are automatic or by request. In most health plans, the guardian of a child can request case management services and skip the delay of waiting until the claims history indicates a need.

Health care providers participating in the managed care network can also initiate case management through a referral. Physicians and facilities partner with the managed care plan to help identify children/families needing support in coordinating care. The assigned case manager is typically a registered nurse or social worker. The child’s case manager works with the parent/caregiver and the child as well as providers to develop an individual health care plan based on a health assessment, and goals. The case manager knows what is available in the managed care network, giving the family information on how to most effectively access services needed. The case manager monitors services even those provided outside the HMO or PPO. The managed care case manager acts as an advocate for the child, recommending services outside the network when access is not possible inside of contracted providers. An advantage of the case manager in managed care plans, is the provision of continuity across in and out of network care resulting in better coordination of services to meet the child’s needs.

Case management programs in managed care plans are designed to provide support to children with special needs and their families, while linking them to resources and services in their own communities (Wise et al., 2007). Case managers are professionally prepared individuals and often act as a mediator between family and the service delivery system as they perform individual service planning, service coordination and monitoring as they understand available benefits of the plan as well as clinical and social needs of the child/family.

Many managed care plans offer field case management. It is important to identify if field case management is a benefit of the benefit plan of the child with special needs. This is especially important if the child has ongoing medical or therapy services. The field case manager comes to the home and helps evaluate what is needed and satisfaction with the network providers delivering care. They can also meet the child/family at the doctor’s office or therapist appointment to assist in coordination of care and referrals that may be needed.