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​​Medicaid Coronavirus Disease 2019 (COVID-19) Updates

HealthChoice

What is a Managed Care Organization (MCO)?

• An MCO is a healthcare arrangement that provides services to Medicaid recipients by contracting with a network of licensed/certified healthcare providers.
  

• All MCOs are responsible to provide or arrange for a wide array of healthcare services. The services and the MCOs responsibilities are described in the HealthChoice MCO Provider Understanding.
  

Phone call the HealthChoice Help Line at 1-800-284-4510, if you

• Have questions virtually HealthChoice benefits

• Take issues getting services from your MCO

• Have questions almost services that are non covered by the MCO but may be covered by Medicaid

Participating HealthChoice MCOs

For additional information near each of the ix MCOs click on the link to a higher place.

How will beneficiaries know if they must enroll in an MCO and choose a Primary Care Provider?

For those who enroll in Medicaid through Maryland Health Connectedness

• Log into your account www.marylandhealthconnection.gov; or

• Download Maryland Health Connection'due south free mobile app, Enroll MHC; or

• Telephone call Maryland Health Connectedness at one-855-642-8572

Those that go through the Department of Human Services (DHS) for their Medicaid eligibility:

• Telephone call Maryland Wellness Connexion at 1-855-642-8572; or

• Complete the form y'all received in your enrollment toolkit and mail in.

If you do not choose an MCO the State will automatically assign you to an MCO.

Who is not eligible to enroll in an MCO?

Medicaid beneficiaries are not eligible for HealthChoice if they:

• Are on Medicare
• Are 65 years or older
• Are only eligible for Medicaid under spend downwardly
• Are in program with limited benefits such equally the Maryland Family unit Planning Program
• Are in an intermediate care facility for mentally retarded persons (ICF-MR)
• Are in Model Waiver Plan
• Are already in a long term care facility or are expected to demand more than ninety days of stay
• Have been in an establishment for mental disease (IMD) for xxx days.
• Are eligible for the Rare and Expensive Case Management (REM) Program and take elected to enroll in REM

 What services are provided nether the HealthChoice program?

All HealthChoice MCOs must embrace basic wellness care benefits such as:

• Visits to the doctor, including regular check-ups
• Healthy Kids check-ups including immunizations
• Prescription drugs (No chemist's copays for children under 21 & significant women)
• X-ray and lab services
• Urgent care middle services
• Emergency services (also covered out of land)
• Hospital services
• Well women intendance
• Prenatal and postpartum care
• Family unit planning and birth control (No pharmacy copays)
• Home health services
• Vision exam & glasses for children nether 21
• Hearing Aids
• Dental care for children under 21 and pregnant women – Call the Maryland Healthy Smiles Dental Program, at 1-855-934-9812
• HIV/AIDS drugs

What other services do MCOs provide?

Other services related to the patient's healthcare such as:

• Outreach and domicile visits for certain special needs and hard-to-reach populations
• Case direction for special populations
• Illness Management for chronic conditions
• Assistance with analogous transportation through the local health departments and limited transportation assistance to medical appointments
• Wellness care providers are required to provide language interpretation.
• Most MCOs offering limited adult dental services.
• Virtually MCOs offering limited over the counter drugs.

Are long term care services provided?

If a Health Option beneficiary requires more than days in a long term intendance facility than is covered past the MCO (currently ninety days or less) they must use for Medicaid long term care (LTC) benefits.  LTC eligibility requirements are more restrictive than HealthChoice.

What are the boosted HealthChoice benefits that are covered by Medicaid and that are not covered by MCOs?

• Behavioral health services
• specialty mental health services like counselors, psychologists, psychiatrists
• substance use disorder treatment and recovery services

Optum

• Outpatient physical therapy, speech therapy, occupational therapy services for children nether 21
• Personal care services – Medical day intendance services for adults or children
• Special support services for individuals with developmental disabilities under the Developmental Disabilities (DD) Waiver
• Wellness related services and targeted case management services provided to children under the child's Individualized Education Plan (IEP) or Individualized Family Service Plan(IFSP)
• Viral load testing services, genotypic, phenotypic, or other HIV/AIDS drug resistance testing
• Non- emergency medical transportation services may be available through the local health section

LHD Transportation

What is the REM Program?

The Rare and Expensive Case Direction (REM) program is a case managed fee-for-service alternative to HealthChoice Managed Care Organization (MCO) participation for recipients with specified rare and expensive weather condition.  ​​​

Criteria for Participation:

A person must exist eligible for HealthChoice in order to receive REM services. Also, the REM Plan is limited to individuals with sure qualifying conditions or diseases. Information regarding these diseases may be obtained by calling ane-800-565-8190.

When can a HealthChoice member go to an out-of-network provider without a referral?

• Check with the MCO. Each MCO has rules about when a referral is needed for specialty care and near MCOs require all services to exist obtained from providers in network.

• HealthChoice does not encompass services when a fellow member is out of state except for emergencies.

There are a number of services that MCOs are responsible to comprehend even when the provider is non in the MCOs network. These are called cocky-referred services and include:

• Emergency services
• Family planning services
• Services provided by schoolhouse-based health center services ervices provided by school-based wellness eye services
• Pregnancy-related services initiated prior to MCO enrollment
• Prenatal, intrapartum, and postpartum services performed at a free-continuing birth centre located in Maryland or a contiguous state
• Newborn's initial medical exam in the infirmary
• Child in State supervised care – initial medical examination past EPSDT certified provider
• HIV/AIDS annual diagnostic and evaluation service visit
• Renal dialysis services provided in a Medicare certified facility

Additional Member Correct to Use Non-Participating Providers

The Maryland Insurance Administration (MIA) also requires all insurers, including HealthChoice MCOs, to let members to continue to see a provider nether certain circumstances for continuity of care reasons.

• The fellow member must have one or more of the following types of conditions:

1. Acute conditions
   
2. Serious chronic conditions
   
3. Pregnancy
   
4. Any other condition upon which their MCO and the out-of-network provider agree

• The member must contact the MCO and make the asking.

The fourth dimension limit for the services from an out-of-network provider for all conditions above except for pregnancy:

• 90 days measured from the appointment the member's coverage starts under the new programme
  

​Or​

• Until the course of treatment is completed

For pregnancy, the time limit lasts through the pregnancy and the first visit to a wellness care provider afterwards the infant is born.

For boosted data about HealthChoice:

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Source: https://health.maryland.gov/mmcp/healthchoice/pages/home.aspx

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