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Accordion Name : Annual QA Activities (8)
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| Annual QA Activities | Annual Technical Reports | | 1 |
| Annual QA Activities | 2024 | | 2 |
| Annual QA Activities | 2023 | | 3 |
| Annual QA Activities | 2022 | | 4 |
| Annual QA Activities | 2021 | | 5 |
| Annual QA Activities | 2020 | | 6 |
| Annual QA Activities | 2019 | | 7 |
| Annual QA Activities | 2018 | | 8 |
Accordion Name : Award Forums (7)
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| Award Forums | 2024 | The 2024 Post-Award Forum took place on Thursday, May 23rd, 2024, during the Maryland Medicaid Advisory Committee meeting, from 1:00 to 3:00 PM via GoToWebinar.
Meeting Reference Documents
| 1 |
| Award Forums | 2023 | The 2023 Post-Award Forum took place on Thursday, May 25th, 2023, during the Maryland Medicaid Advisory Committee meeting, from 1:00 - 3:00 PM via GoToWebinar.
Meeting Reference Documents | 2 |
| Award Forums | 2022 | The 2022 Post-Award Forum took place on Thursday, May 26, 2022, during the Maryland Medicaid Advisory Committee meeting. Due to COVID-19, the meeting was held via webinar. Meeting Reference Documents | 3 |
| Award Forums | 2021 | The 2021 Post-Award Forum took place on Thursday, May 27, 2021. Due to COVID-19, the meeting was held via webinar and in conjunction with the second HealthChoice Waiver Renewal Public Hearing. Meeting Reference Documents
| 4 |
| Award Forums | 2020 | The 2020 Post-Award Forum took place on Thursday, May 28, 2020. Due to COVID-19, the meeting was held via webinar. Meeting Reference Documents | 5 |
| Award Forums | 2019 | The 2019 Post-Award Forum took place on Thursday, May 23, 2019 at 3:00 in room L1 at the Maryland Department of Health (MDH) in Baltimore, Maryland. The Post-Award Forum was held in conjunction with the HealthChoice Waiver Amendment Baltimore Public Hearing. Meeting Reference Documents | 6 |
| Award Forums | 2018 | The 2018 Post-Award Forum took place on Thursday, May 24, 2018 at 3:00 in room L1 at MDH in Baltimore, Maryland. The Post-Award Forum was held in conjunction with the HealthChoice Waiver Amendment Baltimore Public Hearing. Meeting Reference Documents | 7 |
Accordion Name : Financial Statements (1)
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| Financial Statements | MCO Audited Financial Statements | HealthChoice Consolidated Financial Monitoring Reports
| 1 |
Accordion Name : HC Manuals (1)
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| HC Manuals | HC Manual Templates by Year | Member Manual TemplatesProvider Manual Templates | 1 |
Accordion Name : HealthChoice (11)
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| HealthChoice | What is a Managed Care Organization (MCO)? | - An MCO is a healthcare organization 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 Agreement.
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| HealthChoice | Call the HealthChoice Help Line at 1-800-284-4510, if you | - Have questions about HealthChoice benefits.
- Have problems getting services from your MCO.
- Have questions about services that are not covered by the MCO but may be covered by Medicaid.
| 2 |
| HealthChoice | 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 Connection:
- Log into your account www.marylandhealthconnection.gov; or
- Download Maryland Health Connection’s free mobile app, or
- Call Maryland Health Connection at 1-855-642-8572
Those that go through the Department of Human Services (DHS) for their Medicaid eligibility: - Call Maryland Health Connection at 1-855-642-8572; or
- Complete the form you received in your enrollment toolkit and mail in.
If you do not choose an MCO, the State will automatically assign you to an MCO. | 4 |
| HealthChoice | 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 down.
- Are in program with limited benefits such as the Maryland Family Planning Program.
- Are in an intermediate care facility for mentally retarded persons (ICF-MR).
- Are in Model Waiver Program.
- Are already in a long term care facility or are expected to need more than 90 days of stay.
- Have been in an institution for mental disease (IMD) for 30 days.
- Are eligible for the Rare and Expensive Case Management (REM) Program and have elected to enroll in REM.
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| HealthChoice | What services are provided under the HealthChoice program? | All HealthChoice MCOs must cover basic health care benefits such as:
- Visits to the doctor, including regular check-ups
- Healthy Kids check-ups including immunizations
- Prescription drugs (No pharmacy copays for children under 21 & pregnant women)
- X-ray and lab services
- Urgent care center services
- Emergency services (also covered out of state)
- Hospital services
- Well women care
- Prenatal and postpartum care
- Family planning and birth control (No pharmacy copays)
- Home health services
- Vision exam & glasses for children under 21
- Hearing Aids
- Dental care - See the Maryland Healthy Smiles Dental Program or call 1-855-934-9812.
- HIV/AIDS drugs
| 6 |
| HealthChoice | What other services do MCOs provide? | Other services related to the patient’s healthcare such as: - Outreach and home visits for certain special needs and hard-to-reach populations.
- Case management for special populations.
- Disease Management for chronic conditions.
- Assistance with coordinating transportation through the local health departments and limited transportation assistance to medical appointments.
- Health care providers are required to provide language interpretation.
- Most MCOs offer limited over the counter drugs.
For more information see the MCO Comparison Chart.
| 7 |
| HealthChoice | Are long term care services provided? | If a Health Choice beneficiary requires more days in a long term care facility than is covered by the MCO, (currently 90 days or less) they must apply for Medicaid long term care (LTC) benefits. LTC eligibility requirements are more restrictive than HealthChoice. For more information see, Medicaid Long Term Services & Supports (LTSS). | 8 |
| HealthChoice | What are the additional 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
- For more information, see Optum
- Outpatient physical therapy, speech therapy, occupational therapy services for children under 21
- Personal care services – Medical day care services for adults or children
- Special support services for individuals with developmental disabilities under the Developmental Disabilities (DD) Waiver
- Health 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 department
| 9 |
| HealthChoice | What is the REM Program? | The Rare and Expensive Case Management (REM) program is a case managed fee-for-service alternative to HealthChoice Managed Care Organization (MCO) participation for recipients with specified rare and expensive conditions. Criteria for Participation: - A person must be eligible for HealthChoice in order to receive REM services.
- Also, the REM Program is limited to individuals with certain qualifying conditions or diseases. Information regarding these diseases may be obtained by calling 1-800-565-8190.
Learn more, see the REM Program. | 10 |
| HealthChoice | 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 most MCOs require all services to be obtained from providers in network.
- HealthChoice does not cover services when a member is out of state except for emergencies.
There are a number of services that MCOs are responsible to cover even when the provider is not in the MCOs network. These are called self-referred services and include: - Emergency services
- Family planning services
- Services provided by school-based health center services ervices provided by school-based health center services
- Pregnancy-related services initiated prior to MCO enrollment
- Prenatal, intrapartum, and postpartum services performed at a free-standing birth center located in Maryland or a contiguous state
- Newborn’s initial medical exam in the hospital
- Child in State supervised care – initial medical exam by EPSDT certified provider
- HIV/AIDS annual diagnostic and evaluation service visit
- Renal dialysis services provided in a Medicare certified facility
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| HealthChoice | Additional Member Right to Use Non-Participating Providers | The Maryland Insurance Administration (MIA) also requires all insurers, including HealthChoice MCOs, to allow members to continue to see a provider under certain circumstances for continuity of care reasons.
The time limit for the services from an out-of-network provider for all conditions above except for pregnancy:
- 90 days measured from the date the member’s coverage starts under the new plan or
- Until the course of treatment is completed
For pregnancy, the time limit lasts through the pregnancy and the first visit to a health care provider after the baby is born. | 12 |
Accordion Name : Independent Review (5)
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| Independent Review | How do I appeal an MCO claims denial for a medical necessity? | Before requesting an independent review of a medical necessity case, you must first work with the MCO to resolve the dispute.
- Each MCO’s internal appeals process for providers follows the guidance in COMAR 10.67.09.03.
- MCOs are responsible for resolving provider appeals within 90 business days of the initial filing, regardless of the number of appeal levels.
If your appeal does not complete all levels of the MCO internal appeals process, Maximus will not review your case. Be sure to meet all appeal filing deadlines. After you receive your final appeal decision letter from the MCO for a medical necessity claim, you can file your case with Maximus. - You have 30 calendar days from the date of the MCO's final appeal decision letter to file a case for independent review with Maximus.
The entire independent review process is on the Maximus portal. To request a review, you must: - Register for an account.
- Sign and upload a case review agreement.
- Upload your final appeal decision letter.
Maximus will request the appeals record from the MCO. Once the MCO sends the record, Maximus will resolve the dispute within 30 calendar days.
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| Independent Review | Does Maximus charge a fee for a case review? | Yes, maximus only charges a fee after making the case determination. - If Maximus upholds the MCO’s denial, you must pay the fee.
- If Maximus reverses the MCO’s denial, the MCO must pay the fee.
See the fee schedule below. The fee will increase each year by $10 on October 15. - Oct. 15, 2022 - Oct. 14, 2023: $355
- Oct. 15, 2023 - Oct. 14, 2024: $365
See the Maximus portal for information on submitting payments. | 2 |