Enrollees with special health care needs can get Special Coverage that will provide services for the care they need. The special health care needs are:
Aplastic Anemia
Rheumatoid Arthritis
Autism
Cancer
Skin Cancer such as Invasive Melanoma or squamous cells with evidence of metastasis.
Skin Cancer - Carcinoma IN SITU
Chronic Renal Disease (Levels 3-5)
Scleroderma
Multiple Sclerosis (MS) and Amyotrophic Lateral Sclerosis (ALS)
Cystic Fibrosis
Hemophilia
Leprosy
Systemic Lupus Erythematosus(SLE)
Children with Special Health Needs
Obstetric
Tuberculosis (Tb)
HIV/AIDS
Adults with phenylketonuria (PKU)
Pulmonary Hypertension
Your PCP or your Primary Medical Group can give you more information on which people qualify for the special coverage. If you qualify for Special Coverage, they can also help you sign up for it.
People with Special Coverage can choose any provider that works with your Preferred Provider Network or your Insurer’s General Network. People with Special Coverage can get prescription medications, tests and other services through the Special Coverage without a referral or needing their PCP to sign off.
Your Insurer will let you know if you are qualified and will, if you are, make sure that you get access to the services. Vital Plan Special Coverage will begin when the enrollee reaches the limits of the Special Coverage for any other health plan.
The benefits under Special Coverage include the list below. Some services may have limits. Contact your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired) if you want more information.
Coronary disease services and intensive care
Maxillary surgery
Neurosurgical and cardiovascular procedures
Peritoneal dialysis and related services
Clinical services and laboratory tests
Neonatal intensive care unit services
Chemotherapy, radiology and related services
Gastrointestinal conditions, allergies and nutritional evaluation for autistic patients
Procedures and diagnostic tests, when medically necessary
Physical therapy
General Anesthesia
Hyperbaric chamber
Immunosuppressive medicines and laboratory tests for patients who have received transplants
Treatment for specific conditions after diagnosis:
Positive HIV Factor and Acquired Immunodeficiency Syndrome (AIDS) – Ambulatory and hospitalization services are included. You do not need a Referral or Prior-Authorization from your Insurer or your PCP for visits and treatment at the Immunology Regional Clinics of the Health Department;
Tuberculosis;
Leprosy;
Lupus;
Cystic fibrosis;
Cancer;
Hemophilia;
Aplastics Anemia;
Reumatoid Artritis ;
Autism;
OBG Obstetricians;
Post Organ Transplantation; and
Children with special needs. Except:
Asthma and diabetes
Psychiatric disorders, and
Catastrophic diseases for persons with Intellectual disabilities
Scleroderma
Multiple Sclerosis (MS) and Amyotrophic Lateral Sclerosis (ALS)
Services for the Treatment of conditions resulting from self-inflicted damage or as a result of a felony committed by a beneficiary or negligence.
Chronic renal disease
Medications required for the ambulatory Treatment of Tuberculosis and Leprosy
If you have HIV or AIDS, your PCP must ask your Insurer to give you Special Coverage. Once your Insurer adds you to Special Coverage, they will mail you a letter letting you know that you can get services under Special Coverage. The letter will let you know when the Special Coverage starts and when it will stop.
Once you have the letter, you can get all services and treatments for your condition like prescription medicines, laboratory tests, x-rays and other services without your PCP needing to sign off.
You must get your prescription medicines for HIV/AIDS at the Department of Health’s Centers for Prevention and Treatment of Communicable Diseases. Here they are:
Centers for the Prevention and Treatment of Communicable Diseases (CPTET, for its acronym in Spanish)
Antigua Casa de Salud Hosp. Regional Bayamón Dr. Ramón Ruíz Arnau, Ave. Laurel Santa Juanita Bayamón, PR 00956
CAGUAS
CLINICA SATELITE HUMACAO
(787) 653-0550 Ext. 1142, 1150
Fax (787) 746-2898; 744-8645
(787) 285-5660
Hosp. San Juan Bautista PO Box 8548 Caguas, PR 00726-8548
CDT de Humacao, Dr. Jorge Franceshi Calle Sergio Peña Almodovar Esq. Flor Gerena Humacao, Puerto Rico 00791
CAROLINA
(787)757-1800 Ext. 454, 459 Fax (787)765-5105
Hospital UPR Dr. Federico Trilla
P. O. Box 6021 Carolina, PR 00984-6021 Carretera 3, Km. 8.3
CLETS
(787)754-8118
(787)754-8128
(787)754-8127
P. O. Box 70184 San Juan, PR 00936-8523
Calle José Celso Barbosa Centro Médico de PR Bo. Monacillos, San Juan
FAJARDO
(787)801-1992
(787)801-1995
Calle San Rafael # 55 Fajardo, PR 00738
MAYAGUEZ
(787)834-2115 (787)834- 2118
Centro Médico de Mayagüez Hospital Ramón Emeterio Betances Carr.# 2 Suite 6 Mayagüez, PR 00680
PONCE
(787)842-0948
(787)842-2000
Departamento de Salud Región Ponce Antiguo Hosp. Distrito Ponce Dr. José Gándara Carretara Estatal 14 Bo. Machuelo Ponce, PR 00731
CENTRAL OFFICE
(787)765-2929 Ext. 4026, 4027 Fax (787)274-5523
P.O. Box 70184 San Juan, PR 00936
Ant. Hosp. Psiquiatría Pabellón 1, primer piso, 4ta. Puerta - Terrenos de Centro Médico, Río Piedras
Some people with high needs and special conditions can receive Care Management. If you are eligible for Care Management, nurses, social workers and nutritionists are available to help you create a plan for your care. Your team will review your care plan with you at least once a year, if your health needs change, or if you ask for a review.
You can ask for help through this program by calling your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired). Your doctor, your family, your hospital can also ask for you.
For more information call your Insurer at 1-844-336-3331 (toll free), TTY 787-999-4411 (for the hearing impaired).
If you have certain conditions, you may benefit from your Insurer’s High Cost High Needs program to help you get all the care you need. This program is free.
If your PCP tells you that you have:
Cancer
End-Stage Renal Disease (ESRD)
Multiple Sclerosis
Rheumatoid Arthritis
Diabetes
Asthma
Severe Heart Failure
Hypertension
Chronic Obstructive Pulmonary Disease (COPD)
Depression
Attention-Deficit/Hyperactivity Disorder (ADHD)
Substance Use Disorders
Serious Mental Illness (SMI)
Hemophilia
Autism
Your Insurer will offer you extra help with getting care. Your Insurer may want to send someone to your home to talk to you about your needs and learn which, doctors, tests or other help is needed. Talking to the Insurer about your needs will help them understand the best ways to help you.
MMM MH’s Care Management Program facilitates that certain HCHN Enrollees with medically and socially complex health care needs will be managed by specialized multidisciplinary clinics. These specialized and multidisciplinary clinics are designed to provide integrated support for HCHN enrollees with multiple complex conditions; including social and psychological. Through a collaborative team approach, a multidisciplinary team will provide guidance, support and treatment for Enrollees within the framework of these clinics. Identified enrollees will have comprehensive multi-needs assessment performed which will result in an Individualized Care Plan (ICP). Team collaborators may include Physicians, Services Coordinator, Nurses, Social Worker, Health Educator, Nutritionist, Pharm D, embedded Case Managers, Chronic Care Specialties, and a Mental Health Liaison as identified in the ICP.
Enrollees with High Cost High Needs are those who have long-term or complicated physical, mental, emotional, behavioral or developmental disorders. Such Enrollees may need health and related services beyond those needed by the general population and require ongoing treatment and or monitoring. Initial identification of High Cost High Needs Enrollees will be completed by ASES. In addition, screening tools and guidelines will be used to identify Enrollees as soon as possible after becoming a MMM MH Enrollee. Enrollees may be also be identified through their Primary Care Physician, Treating Specialists or by your Insurer.
If you are identified as a High Cost High Need Enrollee, you will be assigned to a Case Manager. He or she will be your partner in helping you get the health care you need, subject to the Vital Plan coverage, exclusions and limitations. Your Case Manager will contact you by phone to complete an assessment and develop and individual care plan in collaboration with your doctors. This plan will be based on your identified medical and behavioral health care needs. Based on your risk level and needs, you may be enrolled in Care Management, Complex Case Management or Intensive Case Management. With the help of your Primary Care Physician, you (or your Caregiver) and your Case Manager will establish goals to help improve your overall health and well-being with specific interventions to help you meet those goals and objectives.
Your Care Manager will:
-Work with you and your providers to prepare a Care Plan
-Help schedule appointments with your PCP, specialists, and other providers, when needed
-Help you to understand your conditions and how to manage them.
-Connect you to resources in the community that can help you.
- Help you understand your current treatment as well as treatment options
You may also receive Case Manager home visits to further identify your needs and/or provide information and education.
As a participant in a program, your Care Plan will be evaluated regularly, but no less than yearly, to determine your progress. The plan will also be modified when immediate needs are identified. When you accomplish your care plan goals and objectives are met, you may be discharged or referred to a lower level of case or care management, as needed.
MMM Multi Health has developed the OB Registry and Prenatal Program for enrollees who are pregnant. As part of this program, Enrollees are oriented on how they can access the services designed for expecting mothers, with particular focus on needs assessments, the establishment of treatment plans with specific treatment objectives, coordination of care with OBGYN specialists and other subspecialists, communication and monitoring.
The goal of the Prenatal Program is to support Enrollee’s appropriate care choices, provide advice on better self-management practices, and encourage positive health behaviors and adherence to care standards including regular physician visits, disease-appropriate testing, and medication adherence. It also allows Enrollees to access appropriate level of care, including referrals, based on results from an individualized assessment, medical recommendations and the establishment of a care plan. To facilitate the latter process, MMM Multi Health has established a Prenatal Program Team which is in charge of the following:
Assess enrollees’ risk factors
Develop treatment plans with care objectives; including OBGYNs and subspecialists
Provide the necessary support to assist Enrollees meet their health care needs during pregnancy
Follow progress on expected outcomes, coordination and referrals to the appropriate level of care as needed
Monitor and revise the tailored care plan to identify needs for the expecting Enrollee.
Ensure healthy outcomes for the mother and the infant.
Wellness and prevention are fundamental parts of MMM Multi Health's approach to coordinated and integrated health care, especially after considering the impact of chronic health conditions in Puerto Rico. MMM Multi Health has developed services based on prevention and wellness principles. These wellness services allow Enrollees to have access to the following:
Annual health checkups
Women’s health and screening
Healthy body weight, through good nutrition and exercise
Annual dental exam
Appropriate use of the Vital Plan Program, including Service Line
Medical and developmental need for children and adolescents
Immunizations
Behavioral health screening, services and management (depression, schizophrenia, bipolar disorder, ADD & ADHD, substance abuse, anxiety disorders)
The benefits of the aforementioned wellness approach are well known for enrollees, especially within the new model of services: improved clinical outcomes, better utilization of resources, and increased satisfaction. Wellness activities and events are developed according to age group, gender, social and the health needs of Enrollees, in accordance ASES. It seeks to provide education and easy to understand information to improve the health of Enrollees in Vital Plan.
On a monthly basis the MMM Multi Health Wellness team will provide seminars, workshops, educational sessions and face to face interventions on health and wellness subject and risk behaviors that affect our eligible MMM Multi Health beneficiaries in traditional and nontraditional setting that includes health care facilities, schools, and community (private and public) settings. Each setting provides opportunities to reach people using existing social structures. Using nontraditional settings can help encourage informal information sharing within communities through peer social interaction. Reaching out to people in different settings also allows for greater tailoring of health information and education.
