How To Get the AHCCCS Health Care Services You Need: Navigating the Health Care Maze Presenter: Jennifer L. Nye, Staff Attorney Arizona Center for Disability.

Presentación del tema: "How To Get the AHCCCS Health Care Services You Need: Navigating the Health Care Maze Presenter: Jennifer L. Nye, Staff Attorney Arizona Center for Disability."— Transcripción de la presentación:

1 How To Get the AHCCCS Health Care Services You Need: Navigating the Health Care Maze Presenter:
Jennifer L. Nye, Staff Attorney Arizona Center for Disability Law Southwestern Arizona Conference on Disability Rights April 25, 2008 Cómo obtener los servicios de atención médica AHCCCS que usted necesita: Navegando el laberinto de la atención médica Conferenciante: Jennifer L. Nye, Abogada de planta Centro Arizona para la Ley de Discapacidad Conferencia del Suroeste de Arizona sobre Derechos de Discapacidad 25 de abril, 2008

2 Outline of Presentation
Esquema de la presentación Overview of Mandate and Services of the Arizona Center for Disability Law Knowing Your Legal Rights to Healthcare Services 1. Visión general del mandato y servicios del Centro de Arizona para la Ley de Discapacidad 2. Conocimiento de sus derechos legales a servicios médicos

3 Outline of Presentation
Esquema de la presentación a. Healthcare programs available in Arizona b. Services available in each program How to Be a Self-Advocate Questions a. Programas de atención médica disponibles en Arizona b. Servicios disponibles en cada programa 1. Cómo ser su propio defensor  2. Preguntas

4 Overview of Mandate and Services of the Arizona Center for Disability Law
Visión general del mandato y servicios del Centro de Arizona para la Ley de Discapacidad * How many people have heard of Arizona Center for Disability Law?

5 The National Protection and Advocacy System
El sistema nacional de Protección y Abogacía (P&A) Established by the Developmental Disabilities Assistance and Bill of Rights Act of 1975 Originally created in response to abuse and neglect and lack of programming in institutions for persons with disabilities Establecido por la Ley de Asistencia para Discapacidades de Desarrollo y Declaración de Derechos de 1975 Creado originalmente como respuesta al abuso y descuido y la falta de programación en instituciones para personas con discapacidades * DD Act also established state DD Councils and state University Affiliated Programs. In Arizona– Governor’s Council on Developmental Disabilities and Institute for Human Development.

6 The National Protection and Advocacy System
El sistema nacional de Protección y Abogacía Protection and Advocacy agency in every state and territory providing protection to people with disabilities through legally based advocacy Agencia de Protección y Abogacía en cada estado y territorio proporcionando protección a personas con discapacidades a través de abogacía con base legal * DD Act also established state DD Councils and state University Affiliated Programs. In Arizona– Governor’s Council on Developmental Disabilities and Institute for Human Development.

7 Protection and Advocacy in Arizona
Protección y Abogacía en Arizona Arizona Center for Disability Law designated as State’s P&A in 1978 Not-for-profit public interest law firm Funded primarily through federal grants El Centro de Arizona para la Ley de Discapacidad fue designado P&A del Estado en 1978 Despacho de abogados no lucrativo de interés público Financiado principalmente por subvenciones federales Sample of grant money providers: Department of Health and Human Services - Administration on Developmental Disabilities and Center for Mental Health Services, Department of Education – Rehabilitation Services Administration, Governor’s Council on Developmental Disabilities, Arizona Community Foundation

8 Protection and Advocacy in Arizona
Protección y Abogacía en Arizona Dedicated to protecting the rights of individuals with physical, mental, psychiatric, sensory and cognitive disabilities Offices in Tucson and Phoenix staffed with attorneys and advocates Dedicada a proteger los derechos de personas con discapacidades físicas, mentales, psiquiátricas, sensoriales y cognitivas Oficinas en Tucson y Phoenix dotadas de abogados y defensores Sample of grant money providers: Department of Health and Human Services - Administration on Developmental Disabilities and Center for Mental Health Services, Department of Education – Rehabilitation Services Administration, Governor’s Council on Developmental Disabilities, Arizona Community Foundation

9 Our Mission Nuestra Misión
The Arizona Center for Disability Law advocates for the legal rights of persons with disabilities… to be free from abuse, neglect and discrimination to have access to education, health care, housing, jobs and other services in order to maximize independence and achieve equality. El Centro de Arizona para la Ley de Discapacidad aboga por los derechos legales de personas con discapacidades de … estar libres de abuso, descuido y discriminación tener acceso a educación, atención médica, vivienda, empleo y otros servicios para maximizar su independencia y alcanzar la igualdad.

10 Who Does the Center Help?
¿A quién ayuda el Centro? People with disabilities (specific federal funding to assist individuals with certain kinds of disabilities, including developmental disabilities, serious mental illness, traumatic brain injuries) Personas con discapacidades (financiamiento federal específico para asistir a personas con ciertas clases de discapacidades, incluyendo discapacidades de desarrollo, enfermedad mental seria, lesiones cerebrales traumáticas) As mentioned- physical, mental, psychiatric, sensory and cognitive disabilities. If you call the Center for assistance we have to ask you about your disability because of our funding requirements. Center does not handle general legal problems encountered by all people, i.e. probate of an estate, obtaining a divorce, filing for bankruptcy. Center serves individuals whose disability is the reason for discrimination, abuse or neglect or the failure to provide needed services. Demand for Center services far exceeds our resources. On an annual basis, Center adopts priority areas for its services based on public input. These priorities guide the services that we provide and are available upon request. Given our limited resources, we must focus our efforts on cases where advocacy will make a difference. If another organization can handle the matter or the claim has limited merit given the time and resources needed to resolve it, the Center may not be able to take the case.

11 Who Does the Center Help?
¿A quién ayuda el Centro? People with disability-related problems People whose legal problems fall within Center’s priority areas People whose cases have merit and generally where there is no other agency or attorney to solve the problem Personas con problemas relacionados con discapacidad Personas cuyos problemas legales caen dentro de las áreas de prioridad del Centro Personas cuyos casos tienen mérito y en general donde no existe otra agencia ni abogado para resolver el problema As mentioned- physical, mental, psychiatric, sensory and cognitive disabilities. If you call the Center for assistance we have to ask you about your disability because of our funding requirements. Center does not handle general legal problems encountered by all people, i.e. probate of an estate, obtaining a divorce, filing for bankruptcy. Center serves individuals whose disability is the reason for discrimination, abuse or neglect or the failure to provide needed services. Demand for Center services far exceeds our resources. On an annual basis, Center adopts priority areas for its services based on public input. These priorities guide the services that we provide and are available upon request. Given our limited resources, we must focus our efforts on cases where advocacy will make a difference. If another organization can handle the matter or the claim has limited merit given the time and resources needed to resolve it, the Center may not be able to take the case.

12 Kinds of Legal Problems Addressed by the Center
Clases de problemas legales atendidos por el Centro Health Care Mental Health Care Education Employment Housing Access to Public Places, Businesses, Governmental Offices and Community Services Atención médica Atención de salud mental Educación Empleo Vivienda Acceso a lugares públicos, negocios, oficinas gubernamentales y servicios comunitarios The following slides give a few examples of the type of issues handled by each of the Center’s five teams. While they don’t cover all of issues handled by the Center, they will provide you with an idea of the type of work that we do. If you have a question(s) regarding a specific issue, we encourage you to call one of the Center offices. The number for each office and the Center’s address will be displayed later in this presentation.

13 Types of Services Provided by the Center
Tipos de servicios proporcionados por el Centro Advice line to provide information on legal rights Representation of individuals in negotiations, administrative proceedings, and court Impact litigation to remedy systemic problems Línea de asesoría para proveer información sobre derechos legales Representación de personas en negociaciones, procesos administrativos y ante tribunales Litigación de impacto para remediar problemas sistémicos Regularly provide basic information, brief advice, technical assistance to individuals on a variety of topics, including employment, health care, special education Conduct trainings in a number of areas, including special education, employment, work incentives, fair housing Investigator on staff

14 Types of Services Provided by the Center
Tipos de servicios proporcionados por el Centro Investigation of abuse and neglect allegations Outreach and training on legal rights and self-advocacy Technical assistance to groups and individuals on disability-related legal issues Advocacy for policy and legal reforms that benefit people with disabilities Investigación de acusaciones de abuso y descuido Extensión y entrenamiento sobre derechos legales y defensa propia Asistencia técnica a grupos y personas físicas sobre asuntos legales relacionados con discapacidad Abogacía sobre políticas y reformas legales que beneficien a personas con discapacidades Regularly provide basic information, brief advice, technical assistance to individuals on a variety of topics, including employment, health care, special education Conduct trainings in a number of areas, including special education, employment, work incentives, fair housing Investigator on staff

15 Knowing Your Legal Rights to Health Care Services
Conocimiento de sus derechos legales a servicios de atención médica What healthcare programs are available in Arizona? ¿Qué programas de atención médica están disponibles en Arizona?

16 Health Care Programs in Arizona
Programas de atención médica en Arizona Acute Care-AHCCCS/Medicaid Long Term Care- AHCCCS/Medicaid Behavioral Health Services RBHA System AHCCCS/Medicaid SMI System ALTCS System (see flowchart handout) Cuidados intensivos-AHCCCS/Medicaid Cuidados a largo plazo-AHCCCS/Medicaid Servicios de salud del comportamiento Sistema RBHA AHCCCS/Medicaid Sistema SMI Sistema ALTCS (ver hoja informativa de diagrama de flujos

17 Medicaid Medicaid A joint federal and state program that provides health care for people with low incomes and limited resources. Enacted in 1965. Un programa conjunto federal y estatal que proporciona atención médica para personas de bajos ingresos y recursos limitados. Promulgado en 1965.

18 Medicaid Medicaid Largest Public health insurer; covers 1 in 10 Americans and 18% of Arizonans. Consists of acute care services, long term care services, and behavioral health services La mayor aseguradora médica pública; cubre 1 de cada 10 norteamericanos y 18% de los residentes de Arizona. Consiste de servicios de cuidados intensivos, servicios de atención a largo plazo y servicios de salud del comportamiento.

19 Medicaid In Arizona Medicaid en Arizona
Arizona Health Care Cost Containment System (AHCCCS; pronounced “Access”) Entire AHCCCS program run as statewide managed care system; most states are fee for service Sistema de Contención de Costos Médicos de Arizona (AHCCCS; se pronuncia “Access”) El programa AHCCCS completo se maneja como un sistema de atención manejada a nivel estatal; la mayoría de estados tienen cuotas por servicios. Arizona’s waiver expires Sept. 2006 State currently submitting renewal waiver to federal government—Feb. 2006 Impact of managed care system—CAPITATION RATES—paid per person served, not for services actually provided

20 Medicaid In Arizona Medicaid en Arizona
Arizona has a “Waiver” from the federal government (CMS) which exempts it from key requirements of the Social Security Act (Medicaid Act) Arizona tiene una “Dispensa” del gobierno federal (CMS) que la exime de requerimientos clave de la Ley de Seguro Social (Ley Medicaid) Arizona’s waiver expires Sept. 2006 State currently submitting renewal waiver to federal government—Feb. 2006 Impact of managed care system—CAPITATION RATES—paid per person served, not for services actually provided

21 Medicaid in Arizona Medicaid en Arizona
1982 Arizona last state in country to join Medicaid 1987 Long Term Care Program started 1995 Behavioral Health Services started As of March 1, 2008 1,071,196 enrolled in AHCCCS (acute care) 42,922 enrolled in Arizona Long Term Care System (ALTCS; pronounced “Altecs”) 1982 Arizona último estado del país en incorporarse a Medicaid 1987 inicio del Programa de Atención a Largo Plazo 1995 inicio de Servicios de Salud del Comportamiento Al 1 de marzo, 2008 inscritos en AHCCCS (cuidados intensivos) inscritos en Sistema de Atención a Largo Plazo de Arizona (ALTCS; se pronuncia “Altecs”)

22 AHCCCS Acute Health Care
Cuidados Médicos Intensivos AHCCCS Eligibility depends on income, resources, residency and other requirements—no disability requirement 8 health care plans provide acute care statewide—2 in Yuma County APIPA Mercy Care Plan Assigned or can pick health plan based on county you live in La elegibilidad depende de los ingresos, recursos, residencia y otros requerimientos—no hay requerimiento de discapacidad 8 planes de atención médica proveen cuidados intensivos en el estado—2 en el Condado de Yuma APIPA Plan Mercy Care Asignado o puede escoger plan médico basado en el condado en donde usted vive

23 Arizona Long Term Care Services (ALTCS)
Servicios de Atención a Largo Plazo de Arizona (ALTCS) Medicaid/AHCCCS program that provides long term care for eligible people Financial and disability requirements Must be at risk of institutionalization to be eligible for services (PAS test) 9 health care plans provide long term care Bridgeway & DDD in Yuma County Programa Medicaid/AHCCCS que provee atención a largo plazo para personas elegibles Requerimientos financieros y de discapacidad Tiene que correr riesgo de institucionalización para ser elegible para servicios (prueba PAS) 9 planes de atención médica proporcionan atención a largo plazo Bridgeway y DDD en el Condado de Yuma

24 Behavioral Health Programs
Programas de Salud del Comportamiento AHCCCS/Medicaid behavioral health services provided by 4 Regional Behavioral Health Authorities (RBHAs) in Arizona Servicios de salud del comportamiento AHCCCS/Medicaid proporcionados por 4 Autoridades Regionales de Salud del Comportamiento (RBHAs) en Arizona

25 Behavioral Health Programs
Programas de Salud del Comportamiento Cenpatico (Yuma County) Community Partnership of Southern Arizona (CPSA) Magellan Northern Arizona Regional Behavioral Health Authority (NARBHA) Cenpatico (Condado de Yuma) Asociación Comunitaria del Sur de Arizona (CPSA) Magellan Autoridad Regional de Salud del Comportamiento del Norte de Arizona (NARBHA)

26 Info about RBHA System Información sobre el Sistema RBHA
Provide services with Medicaid/AHCCCS money and state money Provide services to kids and adults Programs Seriously Mentally Ill (SMI) System (only applies to adults and eligibility depends on disability, not income) General Mental Health Substance Abuse System Provee servicios con fondos Medicaid/AHCCCS y fondos estatales Provee servicios a niños y adultos Programas Sistema de Enfermedad Mental Seria (SMI) (se aplica solamente a adultos, y la elegibilidad depende de discapacidad, no de ingresos) Salud mental en general Sistema de abuso de sustancias SMI system result of Arnold v. Sarn (1989) lawsuit—set to end 2008 Alleged state failed to provide adequate services to people with serious mental illness Funds services to adults with SMI, even if not eligible for AHCCCS To be eligible for mental health services, must have mental health diagnosis and functional limitations related to diagnosis Kids services governed by JK v. Eden settlement (2001)—set to end 2007 Class is children under 21 eligible for AHCCCS Established vision and 12 principles

27 Other Behavioral Health Programs
Otros programas de salud del comportamiento For people (kids and adults) enrolled in ALTCS (except DDD ALTCS) the ALTCS provider provides behavioral health services Para personas (niños y adultos) inscritas en ALTCS (excepto DDD ALTCS) el proveedor ALTCS proporciona servicios de salud del comportamiento.

28 Other Behavioral Health Programs
Otros programas de salud del comportamiento 5 Arizona Tribes also provide behavioral health services (Navajo Nation, Pascua Yaqui, Gila River Indian Community, White Mnt. Apache Tribe of AZ, and Colorado River Indian Tribe) 5 Tribus de Arizona también proveen servicios de salud del comportamiento (Nación Navajo, Pascua Yaqui, Comunidad Indígena del Río Gila, Tribu Apache de White Mountains de AZ y Tribu Indígena del Río Colorado)

29 Other Health Services Available
Otros servicios médicos disponibles KidsCare For low income children under 19 whose family income is too high to qualify for other programs, such as AHCCCS KidsCare Para niños de bajos ingresos menores de 19 años cuyos ingresos familiares son muy elevados para calificar para otros programas, tal como AHCCCS

30 Other Health Services Available
Otros servicios médicos disponibles Children’s Rehabilitative Services (CRS) Provides treatment to people under 21 in Arizona who have a qualifying disability or illness; run by Arizona Department of Health Services Servicios de Rehabilitación de Niños (CRS)  Proporciona tratamiento a personas menores de 21 años en Arizona que tienen una discapacidad o enfermedad calificadora; administrado por el Departamento de Servicios de Salud de Arizona

31 Other Health Services Available
Otros servicios médicos disponibles Division of Developmental Disabilities (DDD) Provides services to children and adults diagnosed with (1) mental retardation (2) autism (3) cerebral palsy or (4) epilepsy before 18 AND División de Discapacidades de Desarrollo (DDD) Proporciona servicios a niños y adultos diagnosticados con (1) retraso mental, (2) autismo, (3) parálisis cerebral, o (4) epilepsia antes de cumplir 18, Y

32 Other Health Services Available
Otros servicios médicos disponibles que tienen limitaciones en 3 de 7 actividades principales de la vida (cuidarse a sí mismo; lenguaje; aprendizaje; movilidad; autodirección; capacidad para vivir independiente; autosuficiencia económica) Medicare Programa de seguro médico federal para personas mayores de 65 años, algunas personas menores de 65 años que estén discapacitadas, y personas con enfermedad renal en etapa final who have limitations in 3 of 7 major life activities (self-care; language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency) Medicare Federal health insurance program for people over 65, some people under 65 who are disabled, and people with end stage renal disease

33 Knowing Your Legal Rights to Health Care Services
Conocimiento de sus derechos legales a servicios de atención médica What Services are Available in Each Program? ¿Qué servicios están disponibles en cada programa?

34 Your Right to Services Su derecho a servicios
Services provided under Medicaid, AHCCCS, ALTCS, and the SMI System are ENTITLEMENTS This means that you have a RIGHT to services if you can show you need them (that the services are “medically necessary”) Los servicios proporcionados bajo Medicaid, AHCCCS, ALTCS y el Sistema SMI son DERECHOS Esto significa que usted tiene un DERECHO a servicios si usted puede demostrar que los necesita (que los servicios son “médicamente necesarios”)

35 AHCCCS Coverage Requirements
Requerimientos para cobertura AHCCCS For AHCCCS/ALTCS to cover a service, it must be Medically Necessary Cost-effective Federally reimbursable Non-Experimental A covered service A.A.C. R (B) Para que AHCCCS/ALTCS cubra un servicio, tiene que ser: 1. Médicamente necesario 2. Rentable 3. Reembolsable federalmente 4. No experimental 5. Un servicio con cobertura A.A.C. R (B)

36 Medically Necessary Services Are:
Los servicios médicamente necesarios: Medically Necessary Services Are: Listed as covered services by the health plan Provided by physician or licensed health care professional Necessary to Prevent disease or disability or other adverse health condition or Prolong life 1. Están listados como cubiertos por el plan médico 2. Son proporcionados por un médico o un profesional autorizado de atención médica 3. Son necesarios para Prevenir enfermedad o discapacidad u otra condición médica adversa, o Prolongar la vida

37 Cost-Effective Rentable
Arizona does not define “cost-effective” in statute, regulation or policy For ALTCS members generally argue that services under the cost of institutionalized care are cost-effective Use Cost Effectiveness Study / cost of services in care plan to show services cost less than institutionalization Arizona no define “rentable” en leyes, reglamentos o políticas Miembros de ALTCS generalmente argumentan que los servicios de menor costo que la atención institucionalizada son rentables; utilizan el Estudio de Rentabilidad / costo de servicios en el plan de atención para mostrar que los servicios cuestan menos que la institucionalización Cost Effectiveness Study: measures cost of nursing home care against cost of services in the community AHCCCS medical policy manual

38 AHCCCS Acute Care Covered Services
Servicios de cuidados intensivos cubiertos por AHCCCS Physician services Prescription drugs Hospital Services Transportation to medical services Physical, occupational, speech therapies Durable medical equipment and supplies EPSDT services Servicios de médicos Medicamentos recetados Servicios de hospital Transporte a servicios médicos Terapias físicas, ocupacionales, del habla Equipos y suministros médicos duraderos Servicios EPSDT Look in your MEMBER HANDBOOK for a complete list of services. LOOK IN MEMBER HANDBOOD FOR COMPLETE LIST OF COVERED SERVICES

39 AHCCCS Acute Care Covered Services
Servicios de cuidados intensivos cubiertos por AHCCCS Behavioral health services Emergency care Pregnancy care Dialysis X-Rays Lab work Surgery Organ Transplants Servicios de salud del comportamiento Atención de emergencia Atención de embarazo Diálisis Rayos X Trabajo de laboratorio Cirugía Trasplante de órganos Look in your MEMBER HANDBOOK for a complete list of services. LOOK IN MEMBER HANDBOOD FOR COMPLETE LIST OF COVERED SERVICES

40 ALTCS Covered Services
Servicios cubiertos por ALTCS All AHCCCS acute care services Behavioral health services EPSDT services Nursing home services ICF/MR (intermediate care facility for the mentally retarded) Home and Community Based Services Todos los servicios AHCCCS de cuidados intensivos Servicios de salud del comportamiento Servicios EPSDT Servicios de hogar de ancianos ICF/MR (instalación de atención intermedia para retrasados mentales) Servicios basados en el hogar y la comunidad HCBS services allow people to live in their own homes

41 Home & Community Based Services (HCBS)
Servicios basados en el hogar y la comunidad (HCBS) Home & Community Based Services (HCBS) Case management Speech, physical, and occupational therapies Personal care Attendant care Respite Habilitation Home modifications Manejo de Casos Terapias del habla, físicas y ocupacionales Cuidados personales Cuidados a domicilio Descanso Habilitación Modificaciones al hogar

42 Home & Community Based Services (HCBS)
Servicios basados en el hogar y la comunidad (HCBS) Home & Community Based Services (HCBS) Equipos y suministros médicos Sistema de alerta de emergencia Transporte Comidas entregadas a domicilio Cuidados diurnos DD Instalaciones para vida asistida Ayuda médica y enfermera en el domicilio Medical equipment & supplies Emergency alert system Transportation Home delivered meals DD day care Assisted living facilities Home health Aid and Nurse

43 Eligibility for HCBS Services
Elegibilidad para servicios HCBS Cost of home services must be less than cost of institutional (nursing home) services Monthly Nursing Home Rate: Monthly DD Rate: ALTCS measures this with “Cost Effectiveness Study” (CES) El costo de los servicios a domicilio tiene que ser menor que los servicios institucionales (hogar de ancianos) Tasa mensual de hogar de ancianos: Tasa mensual DD: ALTCS lo mide con “Estudio de Rentabilidad” (CES)

44 Impact of HCBS Services
Impacto de servicios HCBS HCBS services have dramatically reduced the numbers of ALTCS members living in nursing homes Los servicios HCBS han reducido dramáticamente la cantidad de miembros de ALTCS que viven en hogares de ancianos. Hogares de Ancianos 95+% 36% HCBS 5% 64% 1989 2005 Nursing homes 95+% 36% HCBS 5% 64% Ball case—problem is quality of HCBS services

45 Special Services for Kids Enrolled in AHCCCS or ALTCS
Servicios especiales para niños inscritos en AHCCCS o ALTCS Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services Mandatory for all children and youth under 21 A comprehensive package of screening, diagnostic, and treatment services Servicios tempranos y periódicos de detección, diagnóstico y tratamiento (EPSDT) Obligatorios para todos los niños y jóvenes menores de 21 años Un paquete integral de servicios de detección, diagnóstico y tratamiento Ekloff case

46 Special Services for Kids Enrolled in AHCCCS or ALTCS
Servicios especiales para niños inscritos en AHCCCS o ALTCS Detección médica, auditiva, visual y dental Todos los tratamientos “necesarios para corregir o mejorar” problemas o condiciones físicas o mentales Medical, hearing, vision and dental screening All treatment “necessary to correct or ameliorate” physical or mental problems or conditions Ekloff case

47 Behavioral Health Services
Servicios de salud del comportamiento Ejemplos de servicios BH SMI y ALTCS Manejo de casos Supervisión y medicamentos psicotrópicos Terapia Manejo del comportamiento Rehabilitación psicosocial (aptitudes para vivir, promoción de salud, preparación para trabajar y apoyo en el empleo) Examples of SMI & ALTCS BH Services: Case management Psychotropic medication & monitoring Therapy Behavioral Management Psychosocial rehabilitation (living skills, health promotion, job coaching and employment support)

48 Behavioral Health Services
Servicios de salud del comportamiento Respite Transportation Look in your MEMBER HANDBOOK for a complete list of services Descanso Transporte Busque en su MANUAL PARA MIEMBROS una lista completa de servicios.

49 SMI Only Mental Health Services
Servicios de salud mental (SMI) solamente SMI Only Mental Health Services Housing Flex Funds (also available for children under 21 enrolled with a RHBA & eligible for AHCCCS) Advocacy from the Office of Human Rights Vivienda Fondos Flex (también disponibles para niños menores de 21 años inscritos con un RHBA y elegibles para AHCCCS) Abogacía de la Oficina de Derechos Humanos

50 How to be a Self-Advocate
Cómo ser su propio defensor Getting the Services You Need Obteniendo los servicios que usted necesita

51 Consejos para abogacía propia
Self-Advocacy Tips Consejos para abogacía propia Tip #1: Know What Health Programs Are Available Tip #2: Know What Services Are Available From the Program Tip #3: Know the Acronyms…and when you don’t know—ASK! Consejo #1: Conozca qué programas médicos están disponibles. Consejo #2: Conozca qué servicios están disponibles mediante el programa. Consejo #3: Conozca los acrónimos ... y cuando no sepa—¡PREGUNTE! Prior slides have addressed tips 1-3 also, keep copies of EVERYTHING BE ORGANIZED

52 Self-Advocacy Tips Consejos para abogacía propia
Tip #4: Know the Process for Getting Services Tip #5: Know What to Do When You’re Told “No” Tip #6: Know When and Where to Ask for Help! Consejo #4: Conozca el proceso para obtener servicios Consejo #5: Conozca qué hacer cuando le digan “No”. Consejo #6: ¡Conozca cuándo y dónde pedir ayuda!

53 Tip #4: Know the Process for Getting the Services You Need
Consejo #4: Conozca el proceso para obtener los servicios que usted necesita. Tip #4: Know the Process for Getting the Services You Need Para cuidados intensivos AHCCCS y servicios ALTCS: 1. Acuda a su médico y/o especialista. 2. Pida a su doctor y/o al especialista que le escriban una carta de necesidad médica o que hagan una evaluación delineando por qué necesita usted el servicio o equipo. For AHCCCS Acute Care and ALTCS Services: See your doctor and/ or specialist 2. Ask your doctor and/or the specialist to write a letter of medical necessity or conduct an evaluation outlining why you need the service or equipment AHCCCS/ALTCS health plan has 14 days to respond in writing to your request for services. This is called a “Notice of Action.”

54 Tip #4: Know the Process for Getting the Services You Need
Consejo #4: Conozca el proceso para obtener los servicios que usted necesita. 3. Have the doctor and/or the specialist submit their request (prescription, letter of medical necessity, evaluation, other documentation) to your insurance company 3. Haga que el doctor y/o el especialista presenten su solicitud (receta, carta de necesidad médica, evaluación, otra documentación) a su compañía aseguradora. AHCCCS/ALTCS health plan has 14 days to respond in writing to your request for services. This is called a “Notice of Action.”

55 Tip #4: Know the Process for Getting the Services You Need
Consejo #4: Conozca el proceso para obtener los servicios que usted necesita. For SMI/ALTCS Behavioral Health Services & Services from DDD: Services developed in treatment planning process. Work with your case manager, family, therapist etc. to create treatment plan Para servicios de salud del comportamiento SMI/ALTCS y servicios de DDD: Servicios desarrollados en el proceso de planificación de tratamiento. Trabaje con su gerente de caso, familia, terapeuta, etc. para crear un plan de tratamiento.

56 Tip #4: Know the Process for Getting the Services You Need
Consejo #4: Conozca el proceso para obtener los servicios que usted necesita. Only sign the treatment plan if you agree with it. Treatment plan should be comprehensive and address therapy, medications, rehabilitation services, vocational resources, transportation etc. Firme el plan de tratamiento solamente si está de acuerdo con el mismo. El plan de tratamiento tiene que ser integral y atender terapia, medicamentos, servicios de rehabilitación, recursos vocacionales, transporte, etc.

57 Tip #5: Know What to do if You’re Told “No”
Consejo #5: Conozca qué hacer cuando le digan “No”. If Your AHCCCS/ ALTCS Plan Says “No” File an Appeal with Health Plan Appeal must be received within 60 days of denial Health plan has 30 days to mail you a written answer Si su plan AHCCCS/ALTCS le dice “No”. 1. Presente una apelación ante el plan médico. La apelación tiene que recibirse dentro de 60 días de la denegación. El plan médico tiene 30 días para enviarle una respuesta escrita por correo. Right to appeal if services denied, reduced, suspended, An individual has a right to written notice Services can continue pending appeal, but consumer may be held liable for costs Adhere to all deadlines on the notice Deciding grievance v. hearing Considerations: Are services being reduced or terminated Risk of harm associated with an extended appeal process How much supporting evidence is currently available – I.e. effective letter of medical necessity; evaluations

58 Tip #5: Know What to do if You’re Told “No”
Consejo #5: Conozca qué hacer cuando le digan “No”. If Appeal Denied, File a “Request for Fair Hearing” Must be received by health plan within 30 days of denial of appeal Hearing will be in front of impartial hearing officer Si la apelación es denegada, presente una “Solicitud de Audiencia Justa”. Tiene que recibirla el plan médico dentro de 30 días de la denegación de la apelación. La audiencia será ante un funcionario de audiencia imparcial. Right to appeal if services denied, reduced, suspended, An individual has a right to written notice Services can continue pending appeal, but consumer may be held liable for costs Adhere to all deadlines on the notice Deciding grievance v. hearing Considerations: Are services being reduced or terminated Risk of harm associated with an extended appeal process How much supporting evidence is currently available – I.e. effective letter of medical necessity; evaluations

59 Tip #5: Know What to do if You’re Told “No”
Consejo #5: Conozca qué hacer cuando le digan “No”. If Your RBHA Provider Says “No” You have right to file appeal under SMI Rules or AHCCCS Rules, depending on eligibility Si su proveedor RBHA dice “No”: 1. Usted tiene derecho a presentar una apelación conforme a las Reglas SMI o las Reglas AHCCCS, dependiendo de la elegibilidad.

60 Tip #5: Know What to do if You’re Told “No”
Consejo #5: Conozca qué hacer cuando le digan “No”. Under SMI Rules Have right to advocacy from Office of Human Rights Have right to continuation of services pending appeal Have right to file appeal in writing or verbally RBHA informal conference DBHS informal conference Fair hearing 2. Conforme a las Reglas SMI, usted Tiene derecho a abogacía de la Oficina de Derechos Humanos Tiene derecho a la continuación de los servicios pendiente de la apelación Tiene el derecho de presentar la apelación por escrito o verbalmente Conferencia informal RBHA Conferencia informal DBHS Audiencia justa

61 Tip #6: Know When and Where to Ask for Help
Consejo #6: Conozca cuándo y dónde pedir ayuda. Ask for help when: You’re confused about the process You’ve received a notice and don’t understand it You’ve followed the steps for self-advocacy and still are not getting your needs met Solicite ayuda cuando: Está confundido acerca del proceso; Ha recibido un aviso y no lo entiende; Ha seguido los pasos de defenderse a sí mismo y todavía no satisfacen sus necesidades.

62 Tip #6: Know When and Where to Ask for Help
Consejo #6: Conozca cuándo y dónde pedir ayuda. Where to Look For / Ask For Help AHCCCS/ALTCS State Health Insurance Assistance Program (for questions about Medicare) Dónde buscar/solicitar ayuda AHCCCS/ALTCS Programa de Asistencia de Seguro Médico Estatal (para preguntas sobre Medicare)

63 Tip #6: Know When and Where to Ask for Help
Consejo #6: Conozca cuándo y dónde pedir ayuda. RBHA Mental Health Services Division of Developmental Disabilities (DDD) Community Legal Services (Legal Aid) or Servicios de Salud Mental RBHA División de Discapacidades de Desarrollo (DDD) Servicios Legales Comunitarios (Legal Aid) o

64 ACDL General Contact Information Información general para comunicarse con ACDL Our Advocates, lawyers & staff are here to serve you Phoenix Office-Short Term Assistance Line 3839 North Third Street, Suite 209 Phoenix, Arizona 85012 (voice or TTY) (toll free) (fax) Nuestros defensores, abogados y personal están aquí para servirle. Oficina de Phoenix - Línea de asistencia a corto plazo 3839 North Third Street, Suite 209 Phoenix, Arizona 85012 (voz o teletipo) (sin costo) (fax)

65 Questions? ¿Preguntas?