{"id":917,"date":"2015-04-07T16:15:37","date_gmt":"2015-04-07T16:15:37","guid":{"rendered":"http:declasi.org\/news-and-stories\/uncategorized\/how-to-manage-your-delaware-managed-care-organization\/"},"modified":"2026-02-09T10:29:39","modified_gmt":"2026-02-09T15:29:39","slug":"how-to-manage-your-delaware-managed-care-organization","status":"publish","type":"post","link":"https:\/\/www.declasi.org\/es\/news-and-stories\/disability\/how-to-manage-your-delaware-managed-care-organization\/","title":{"rendered":"How to Manage Your Delaware Managed Care Organization"},"content":{"rendered":"<p>Here are some important tips regarding your rights as a recipient of services from a Medicaid Managed Care Organization (MCO). You can also download the <a href=\"http:\/\/www.declasi.org\/wp-content\/uploads\/2015\/04\/How-to-Manage-your-Managed-Care-Organization.pdf\" target=\"_blank\">flyer here<\/a>.<\/p>\n<p>1. \u00a0You have a right to disagree with your MCO and with the MCO care coordinator, and the right to ask for more or different services. \u00a0Remember, services must be ordered by a health care provider.<\/p>\n<p>2. \u00a0You have a right to a written notice at least 10 days before any decision to terminate, suspend or reduce any existing service.\u00a0 If your service provider tells you that your MCO is reducing your services and you have not gotten a notice, you need to tell the service provider and your MCO that they cannot reduce your services without giving you prior, written notice and the opportunity to appeal.<\/p>\n<p>3.\u00a0\u00a0You have appeal rights whenever your MCO is proposing to terminate,\u00a0 suspend or reduce an existing service , refusing to re-authorize an existing service, denying a request for a new service or not acting in a timely way.<\/p>\n<p>4.\u00a0\u00a0There are different types of appeals for when you disagree with your MCO.\u00a0 It is important to understand the differences.<\/p>\n<p>a.\u00a0\u00a0<strong>An internal appeal<\/strong> allows you to challenge a decision regarding your care within the MCO system, meaning \u00a0 people the MCO employs or contracts with will be making a decision on your appeal.<\/p>\n<p>i.\u00a0\u00a0You have 90 days from the date your notice was mailed to ask for an internal appeal.<br \/>\nii.\u00a0\u00a0If you request your internal appeal within 10 days of the date the notice was mailed (keep your envelope; \u00a0 \u00a0 sometimes the notice has a date that is earlier than when the MCO actually mailed it!!!) you can get services continued. You have to indicate that you want your services to continue.\u00a0if you lose your appeal you may be held financially responsible for those services.<br \/>\niii. \u00a0You have a right to a representative of your own choosing when you do an internal appeal. You can but \u00a0 \u00a0 \u00a0 you do not have to use the MCO patient advocate.<br \/>\niv. \u00a0You should read your member handbook for more information on other types of appeals, such as expedited appeals and peer to peer (e.g., doctor to doctor) appeals.<\/p>\n<p>b.\u00a0\u00a0<strong>A state fair hearing<\/strong> allows your case to be reviewed by a decision maker who is outside of the MCO.\u00a0 You \u00a0 \u00a0 \u00a0 have a right to request a state fair hearing without filing an internal appeal with an MCO.\u00a0 You can file both. In fact, CLASI generally recommends that you file for both, and that you do so within 10 days of the mailing of your notice if you want your benefits to continue during your appeal.<\/p>\n<p>i.\u00a0\u00a0You have 90 days from the date the Notice of Action is mailed to ask for a state fair hearing.\u00a0 You must put your request in writing and file it with the state fair hearing office.<br \/>\nii.\u00a0\u00a0If you file your written request for a state fair hearing with the state fair hearing office within 10 days of the date of mailing of the notice or before the action date,\u00a0 you can get services continued while you wait for the outcome of your appeal.\u00a0 When you elect for the services to continue during the appeal, you may be financially responsible for the services if you lose your appeal.<br \/>\niii.\u00a0\u00a0You can bring an advocate of your choice to the state fair hearing.\u00a0 Before your hearing, you have a right to review your file and any documents the MCO intends to use at your hearing. \u00a0You also have a right to the rules the MCO used in making its decision, including laws and regulations.<\/p>\n<p>c. <strong>\u00a0An MCO grievance is NOT an appeal<\/strong> and does not challenge the merits of any decision that the MCO has made.\u00a0 It is a way to complain about the manner in which you were treated by a provider or the MCO or its employees.<\/p>\n<p>5.\u00a0\u00a0If your MCO is preparing or revising a Plan of Care and you are not happy with it, you can refuse to accept the Proposed Plan of Care, and indicate that you disagree with it and why.<br \/>\na.\u00a0\u00a0If you refuse to sign it, or sign indicating that you do not agree, you are entitled to a written notice with the opportunity for an internal MCO appeal and a state fair hearing.<br \/>\nb.\u00a0\u00a0Even if you don\u2019t get a notice, you have a right to file a request for a state fair hearing.<\/p>\n<p>Please call Community Legal Aid Society toll free at (800) 292-7980 or seek other legal counsel if your services are changed without getting a notice, or if you receive a notice that the MCO wants to terminate, suspend or reduce an existing service or has denied a service ordered by your treatment source, and you disagree with that decision.<\/p>\n<p>General tips for dealing with a health insurance company, including an MCO:<\/p>\n<p>1.\u00a0\u00a0Document everything.\u00a0 Keep all of your letters with the envelopes stapled to them.<\/p>\n<p>2. Keep a log of every conversation, including the name of the person you spoke to, what you spoke about, and the date and time.<\/p>\n<p>3.\u00a0\u00a0Do not allow someone to make a decision verbally.\u00a0 Insist on a written notice.<\/p>\n<p>4.\u00a0\u00a0Pay close attention to deadlines.<\/p>\n<p>5.\u00a0\u00a0Get a receipt for any documents you give them.\u00a0 Keep copies! Send letters certified mail with a return receipt.\u00a0 This is especially important if you have a deadline or are requesting that your services continue during your appeal \u2013 if the paperwork is lost you need to be able to prove that you filed it on time!<\/p>\n<p>6.\u00a0\u00a0Have the full and complete cooperation of your doctor or service provider.\u00a0 Make sure they agree with your requests for services.\u00a0 If they are required to submit documents to the insurer, make sure to follow up politely and make sure that this was done.<\/p>","protected":false},"excerpt":{"rendered":"<p>Here are some important tips regarding your rights as a recipient of services from a Medicaid Managed Care Organization (MCO). You can also download the flyer here. 1. \u00a0You have a right to disagree with your MCO and with the MCO care coordinator, and the right to ask for more or different services. \u00a0Remember, services [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[20,23,28],"tags":[],"class_list":["post-917","post","type-post","status-publish","format-standard","hentry","category-clasi-updates","category-disability","category-public-benefits"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>How to Manage Your Delaware Managed Care Organization - Community Legal Aid Society, Inc.<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.declasi.org\/es\/news-and-stories\/disability\/how-to-manage-your-delaware-managed-care-organization\/\" \/>\n<meta property=\"og:locale\" content=\"es_ES\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"How to Manage Your Delaware Managed Care Organization - Community Legal Aid Society, Inc.\" \/>\n<meta property=\"og:description\" content=\"Here are some important tips regarding your rights as a recipient of services from a Medicaid Managed Care Organization (MCO). 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