Kev Tswj Fwm Kev Kho Mob Medi-Cal (Medi-Cal Managed Care): Cov Kev Pab Cuam Kho Mob Tsis Koom Tes Ua Pab Pawg

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Kev Tswj Fwm Kev Kho Mob Medi-Cal (Medi-Cal Managed Care): Cov Kev Pab Cuam Kho Mob Tsis Koom Tes Ua Pab Pawg

Cov koos haum tswj hwm kev kho mob Medi-Cal (Medi-Cal managed care organizations, (MCO) uas muaj cov kws kho mob koom tes ua pab pawg, suav nrog cov kws kho mob, cov khw muag tshuaj, cov chaw kho mob , cov chaw ntsuam sim, thiab cov tsev kho mob (“cov phiaj xwm ntawm kws kho mob”). Yuav luag txhua zaus, cov neeg koom siv yuav tsum tau siv cov phiaj xwm teeb raws li ntawm kws kho mob thaum lawv muaj mob txawm rau kev pab cuam pov puag los ntawm MCO. Muaj cov ua piv txwv thaum koj siv kev pab cuam kho mob los ntawm cov kws kho mob uas tsis yog tus muaj cov phiaj xwm ntawm cov kws kho mob. Cov no hu hais tias cov kws kho mob“tsis koom tes ua pab pag”. Cov kev pab cuam uas lawv muab yog raug suav tias yog kev pab cuam “tsis koom tes ua pab pawg”.

1.  Cov kev pab cuam kho mob tsis koom tes ua pab pawg yog dab tsi?

Cov koos haum tswj hwm kev kho mob Medi-Cal (Medi-Cal managed care organizations, (MCO)1 uas muaj cov kws kho mob koom tes ua pab pawg, suav nrog cov kws kho mob, cov khw muag tshuaj, cov chaw kho mob , cov chaw ntsuam sim, thiab cov tsev kho mob (“cov phiaj xwm ntawm kws kho mob”). Yuav luag txhua zaus, cov neeg koom siv yuav tsum tau siv cov phiaj xwm teeb raws li ntawm kws kho mob thaum lawv muaj mob txawm rau kev pab cuam pov puag los ntawm MCO. Muaj cov ua piv txwv thaum koj siv kev pab cuam kho mob los ntawm cov kws kho mob uas tsis yog tus muaj cov phiaj xwm ntawm cov kws kho mob. Cov no hu hais tias cov kws kho mob“tsis koom tes ua pab pag”. Cov kev pab cuam uas lawv muab yog raug suav tias yog kev pab cuam “tsis koom tes ua pab pawg”.

2.  Nyob hauv qab xwm txheej dab tsi ntawm kuv qhov MCO yuav tau them rau cov khws kho mob/cov kev pab cuam uas tsis koom tes ua pab pawg?

Kev Kho Mob Xwm Ceev

Yog koj xav kho mob xwm ceev koj tuaj yeem mus tau rau ntawm tus kws kho mob uas tsis koom tes ua pab pawg. Koj tseem tuaj yeem hu tau rau ntawm MCO tus xov tooj sab laj txog kev kho mob uas tuaj yeem pab tau koj thawm muaj mob kub heev lossis lawm yam kev kho mob. Siv tau ib zaug ntawm chav kho mob kub heev thiab thaum koj tus mob ruaj ntseg lawm koj yuav tau tshem mus kho rau ntawm tus kws khob koom tes ua pab pawg txhawm rau kho tus mob txuas mus ntxiv. Kev pab cuam xa neeg mob nyhav los tuaj yeem raug pov puag.2 Yam uas raug ntsuam xyuas ua “xwm ceev” yog tej yam uas tsim nyog koj ntseeg tias yog xwm txheej xwm ceev. Nws tsis ua ca txawm tias tom qab no nws ho raug txiav txim tias tsis yog kev xwm ceev los xij.

Koj tau txais kev pab cuam los ntawm kev tsis-koom tes ua pab pawg thaum lub sij hawm koj sau npe mus rau kev tswj fwm kev kho mob Medi-Cal (Medi-Cal managed care).

Yog tias koj mus kho mob ntawm tus kws kho mob uas tsis koom tes ua pab pawg thiab tam sim no koj tab tom raug qhia tias koj yuav tsum tau sua npe rau hauv MCO, koj tseem yuav tuaj yeem kho mob ntawm tus kws kho mob no txuas mus ntxiv nyob rau hauv qab no hu hais tias “kev kho mob txuas mus ntxiv (continuity of care).” Xav paub ntau tshaj no hais txog kev kho mob txuas mus ntxiv, mus saib tau rau ntawm:

Tsis muaj cov kws kho mob koom tes ua pab pawg

Yog tias koj xav tau cov kev pab cuam ntawm koj qhov MCO uas yog xav tau tus kws kho mob, tab sis ho tsis muaj cov kws kho mob hauv cov phiaj xwm kws kho mob koom tes ua pab pawg “muaj kev paub txog hauv txoj kev saib nyuas nrog kev xav tau,”3 kev kho mob uas muaj npe koj yuav tuaj yeem tau txais cov kev pab cuam tsis koom tes ua pab pawg. Piv txwv li, yog tia koj xav kho mob ntawm ib tug kws kho mob hlwb me nyuam yau tshwj xeeb, tab sis ho tsis muaj tus kws kho mob hlwb me nyuam yau hauv kev kom tes ua pab pawg ntawm MCO, (MCO’s network) dhau li ntawv koj tuaj yeem kho mob ntawm tus kws kho mob hlwb me nyuam yau uas tsis nyob rau hauv kev koom tes ua pab pawg. Koj qhov MCO yuav tsum pom zoo rau qhov no.

Koj tseem yuav tau txais kev pab cuam los ntawm pab pawg kho mob lossis los ntawm cov pab pawg kws kho mob thiab lawm cov kws kho mob hauv koos haum txawb pab kev kho mob raws leej neeg (individual practice association, IPA). IPA lossis pab pawg kho mob yuav tau muaj daim ntawv cog lus nrog MCO txawm rau muab kev pab cuam rau koj. Pab pawg kuj tseem yuav tsum tau ntsuam xav txog qees yam kev phom sij fab nyiaj txiag ntawm txoj kev muab kev pab cuam kho mob rau koj. Koj yuav tsum tsis txhob muaj kev ciaj ciam rau cov kws kho mob hau pab pawg. koj yuav tsum tuaj yeem mus rau ntawm MCO tus kws kho mob sab nraum pab pawg kho mob lossis IPA thiab tsis muaj kev sab laj nraug rau tus tsis kom tes ua pab pawg.

3.  Yuav ua li ca thaum kuv qhov MCO thiab kuv tsis sib pom zoo rau qhov kuv yuav tsum tau kho mob ntawm ib tug kws kho mob tshwj xeeb?

Yog tias muaj kev tsis sib pom zoo hai txog qhov koj yuav tsum mus kho mob ntawm ib tug kws kho mob tshwj xeeb lossis ib tug kws kho mob faj seeb hauv txoj kev saib xyuas nrog rau kev kho mob uas koj xav tau, koj tuaj yeem nug tau rau lub tswv yim zeeg ob ntawm “tus neeg ua hauj lwm saib xyuas kev noj qab haus huv uas tsim nyog:” kws kho mob ntawm ntiaj tug lossis yog muaj feem xyuam ntawm keeb kwm kho mob, suav nrog muaj feem xyuam ntawm kev cob qhia thiab kev txawj ntse.4

4.  Kuv tau hnov qee yam kev pab cuam uas “raug txiav tawm” los ntawm phiaj xwm MCO. Qhov no txhais tau li ca?

Muaj ib cov kev pab cuam uas MCO tsis tau muab rau vim yog muaj lwm lub koos haum thaj tsob muab rau lawv lawm. Cov kev pab cuam no suav tias yog “raug txiav tawm” lossis tsis pov puag los ntawm MCO. Txawm li ca los xij MCO tsis tau xav kom muab cov kev pab cuam no, phiaj xwm Medi-Cal tseem thaj tsob muab rau lawv. MCO tseem yuav thaj tsob txhawm rau pab koj kom tau txais kev pab cuam raug txiav-tawm uas koj xav tau. Tus kws kho mob tsis nyob hauv MCO thiab tus lees txais Medi-Cal yuav muab kev pab cuam uas raug txiav-tawm. Nyob rau ntawm koj qhov MCO pov puag dab tsi, kev pab cuam raug txiav-tawm tuaj yeem suav nraug cov kev pab cuam los ntawm Cov Kev Pab Cuam Me Nyuam Yau Ntawm California (California Children’s Services, CCS), kev pab cuam,5 shwj xeeb rau kev kho hlwb, kev kho hniav, kho qhov muag tsis pom kev thiab lwm yam kev pab cuam daws cov teeb meem kev quav yeeb quav tshuaj: uas yog, teeb meem dej cawv lossis tshuaj muaj yees. Txhawm rau nkag mus siv cov kev pab cuam no koj tuaj yeem nug kev pab ntawm koj qhov MCO lossis nrhiav peb tau.

5.  Kuv yuav tuaj yeem ua tau li ca yog tias kuv qhov MCO kev pab caum/tus kws kho mob tsis koom tes ua pab pawg?

Koj muaj ntau txoj kev xaiv yog tias koj qhov MCO tsis lees koj txoj kev thov ntawm tus kws kho mob tsis-kom tes ua pab pawg.

Ua ntawv tsis txau siab

.Koj tuaj yeem xa daim ntawv tsis txaus siab tau txhua lub sijhawm. Nug koj qhov MCO seb yuav ua li ca rau qhov no. Yog tias koj qhov teeb meem xwm ceev (yog ib qho kev puas tsuaj loj rau koj lub cev), koj qhov MCO yuav tau txiav txim siab rau koj nyob rau sij hawm 72 xuab moos. Yog tias koj qhov teeb meem tsis xwm ceev, koj qhov MCO muaj sij hawm 30 hnub txiav txim siab rau koj. Yog xav paub ntxiv, nyeem daim ntawv xov xwm txog Disability Rights California:

https://www.disabilityrightsca.org/publications/medi-cal-managed-care-health-plans-what-are-they-what-do-i-need-to-know-about-them

Sau daim ntawv thov kom rov qab soj ntsuam dua

Koj tuaj yeem xa daim ntawv thov rov mus hais dua nrog koj lub MCO. Yog xav paub ntxiv, nyeem daim ntawv xov xwm txog Disability Rights California:

https://www.disabilityrightsca.org/publications/medi-cal-managed-care-health-plans-what-are-they-what-do-i-need-to-know-about-them

Nug tau ntawm Fab Hauj Lawm Saib Xyuas Kev Kho Mob (Department of Managed Health Care) txhawm rau thov kev pab

Ua ntej koj ua ntawv tsis txaus siab nrog Lub Chaw Tswj Kev Tswj Xyuas Kev Kho Mob, koj yuav tsum xub ua ntawv tsis txaus siab los yog thov kom rov qab taug dua nrog koj lub MCO, Raws li cov phiaj xwm MCO feem ntau, koj tuaj yeem xa ntawv tsis txau siab mus rau Fab Hauj Lawm Saib Xyuas Kev Kho Mob (Department of Managed Health Care) ntawm (888) 466-2219 or TDD: (877) 688-9891 yog tias koj tsis txaus siab rau kev txiav txim siab ntawm koj qhov MCO lossis yog tias koj tsis tau txais kev txiav txim siab nyob rau sij hawm 3 hnub rau ntawm teeb meem xwm ceev lossis 30 hnub rau ntawm teeb meem tsis-xwm ceev. Mus saib rau ntawm: https://www.dmhc.ca.gov/FileaComplaint.aspx#.WBJ8JY3FA3E

Koj tuaj yeem hu xov tooj rau Qhov Chaw Thov Kev Pab DMHC (DMHC’s Help Center) ntawm 1 (888) 466-2219. Yog xav paub ntxiv, nyeem daim ntawv xov xwm txog Disability Rights California:

https://www.disabilityrightsca.org/publications/medi-cal-managed-care-health-plans-what-are-they-what-do-i-need-to-know-about-them

Nug tau ntawm Qhov chaw soj ntsuam kho mob ywj siab (Independent medical review)

Koj tuaj yeem nug tau ntawm DMHC txhawm rau soj ntsuam kho mob ywj siab (Independent Medical Review). Ib qho Kev Ntsuam Xyuas Tus Kheej (Independent Medical Review: IMR) yog ib txoj hauv kev rau koj kom tau txais kev kho mob sab nraud, kev kho mob sab nraud yog tias koj txoj kev npaj khomob txwv tsis kam, hloov, lossis qeeb cov kev pabcuam vim yog xav tau kev khomob. Txhawm rau kom paub ntau tshaj no mus nyeem daim ntawv hais txog Disability Rights California: https://www.disabilityrightsca.org/publications/medi-cal-managed-care-an-independent-medical-review-imr-can-change-a-plans-no-to-yes

Nws muaj nuj nqis heev uas koj soj ntsuam DRC ntawv xov xwm ntawm IMRs hais txog ncua sij hawm ntawm kev npaj ua ntaub ntawv IMR thaib kev thov uas ncaj ncees.

Xav ntaub ntawv rau kev ncaj ncees Medi-Cal (Medi-Cal fair hearing)

Pib lub Xya Hli 1, 2017, cov cai tshiab ntawm tsoomfwv yuav tsum kom MCO sau npe tuaj yeem ua lawv cov txheej txheem kev tsis txaus siab ua ntej thov kom muaj lub rooj sib hais ncaj ncees. Qhov no txhais tau tias koj yuav tsum ua daim ntawv tsis txaus siab nrog koj lub MCO ua ntej yog tias koj tsis txaus siab rau koj qhov kev txiav txim siab ntawm MCO. Koj yuav tsum thov Medi-Cal ib qho kev sib hais ncaj ncees hauv 120 hnub txij li hnub tau txais tsab ntawv ceeb toom txog kev daws teeb meem. Txhawm rau thov kom hu rau Medi-Cal ib lub rooj sib hais ncaj ncees. yog hu rau ntawm Qhov Chaw Hais Plaub, (State Hearings Division) Qhov Chaw Tuav Pov Hwm Zej Tsoom (Department of Social Services) hu dawb tau ntawm (800) 952-5253 lossis TDD ntawm (800)952-8349. Koj tuaj yeem rov hais dua tau fax ntawm (916) 651-2789. Yog xav paub ntxiv, nyeem daim ntawv xov xwm txog Disability Rights California:

https://www.disabilityrightsca.org/publications/medi-cal-managed-care-health-plans-what-are-they-what-do-i-need-to-know-about-them

Pauv phiaj xwm

Kev pauv koj qhov phiaj xwm yuav yog ib txoj hauv kev kho mob lo ntawm tus kws kho mob txhua fab uas yauv tuaj yeem daws cov teeb meem kev kho mob ntawm koj tau. Ua ntej thaum koj yuav ua li no, koj yuav tsum tau ntseeg tias MCO uas koj ntawv yuav xav txog kev tshem mus kho mob ntawm lawm tus kho mob uas koj xav tau.

Kev lees paub: Qhov kev tshaj tawm no tsuas yog cov ntaub ntawv raug cai thiab tsis yog lus qhia txog kev cai lij choj ntawm koj tus kheej. Nws yog tam sim no raws li hnub tshaj tawm. Peb sim hloov peb cov ntaub ntawv tsis tu ncua. Txawm li cas los xij, txoj cai hloov tsis tu ncua. Yog tias koj xav paub tseeb tias txoj cai tsis tau hloov, hu rau DRC lossis lwm lub chaw haujlwm raug cai.

 
  • 1. Cov neeg kom siv ntawm MCO xaiv thawj tuag kws kho mob (primary care physician, PCP) uas lawv yuav tsum xub mus ntsib.  Tus PCP tuaj yeem kho los yog xa cov neeg koom siv mus rau tus kws kho mob tshwj xeeb nyob hauv cov chaw kho mob koom tes ua pab pawg thiab qee zaus nyob sab nraum ntawm cov chaw kho mob koom tes ua pab pawg.
  • 2. Mus saib California Kev Noj Qab Haus Huv & Kev Nyab Xeeb (California Health & Safety) ntawm Tus Zauv Tshooj 1371.5.
  • 3. 42 C.F.R. Tshooj 438.56(d)(2)(iv).  Medicaid ntawm Tsoom Fwv tswj hwm cov kev cai kho mob rau kev nrho npe tawm ua yog vim muab  kev pom zoo rau txoj cais uas tsis nyob hauv kev kho mob koom pab pawg txhawm rau kom tau txais kev pab cuam los ntawm tus kws kho mob faj seeb uas muaj kev pab  hauv txoj kev saib xyuas nrog rau tus neeg thov cov kev xav tau ntawm txoj kev kho mob.
  • 4. California Kev Noj Qab Haus Huv & Kev Nyab Xeeb(California Health & Safety) Tus Zauv Tshooj 1383.15(b)
  • 5. mus saib ntawm https://www.disabilityrightsca.org/publications/specialty-mental-health-services-through-a-county-mental-health-plan txhawm rau cov ntaub ntawv kev paub ntawm kev pab cuam kho hlwb tshwj xeeb.  Txhawm rau kev pab cuam kho hlwb koj qhov MCO muab mus saib tau ntawm:  http://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2013/APL13-018.pdf