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 Accordion Name : Annual QA Activities (6)
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| Annual QA Activities | 2023 | | 1 |
| Annual QA Activities | 2022 | | 2 |
| Annual QA Activities | 2021 | | 3 |
| Annual QA Activities | 2020 | | 4 |
| Annual QA Activities | 2019 | | 5 |
| Annual QA Activities | 2018 | | 6 |
| Accordion Name : Award Forums (7)
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| 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 | 1 |
| 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 | 2 |
| 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
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| 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 | 4 |
| 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 | 5 |
| 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 | 6 |
| Award Forums | 2017 | The 2017 Post-Award Forum was held within six months of implementation, as required, on June 22, 2017 at MDH in Baltimore, Maryland. Meeting Reference Documents
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| Accordion Name : Discover HealthChoice (4)
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| Discover HealthChoice | Coverage | Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities.
There are several ways to enroll in Medicaid. Enrollment in Medicaid and the Maryland Children’s Health Program is available any time of year.
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| Discover HealthChoice | Services | Covered Services: 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 individuals) X-ray and lab services Urgent care center services Emergency services (also covered out of state) Hospital and specialty 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 HIV/AIDS drugs
Other Services Provided by MCOs: Other services related to the patient’s healthcare are listed below. Some services vary by MCO. 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.
Additional HealthChoice Benefits Paid For by the State Behavioral health services: Specialty mental health services like counselors, psychologists, psychiatrists Substance use disorder treatment and recovery services Dental care – Call the Maryland Healthy Smiles Dental Program, at 1-855-934-9812
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
Long Term Care Services Long term care facility stays are covered by the MCO for up to 90 days. If a HealthChoice member requires more days in a long term care facility, they must apply for Medicaid long term care benefits. More information can be found here: Medicaid Long Term Services & Supports (LTSS).
Self-Referred Services There are several services that MCOs are responsible to cover even when the provider is not in the MCO’s network. These are called self-referred services and include: Emergency services Family planning services Services provided by school-based health centers 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
Contact your MCO for more information about these services.
Out-of-Network Provider Services 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.
If an MCO does not have network providers available for a covered service, the MCO is responsible for arranging out-of-network care for the member until they have providers in the network.
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 member must have one or more of the following types of conditions: Acute conditions 3. Pregnancy Serious chronic conditions 4. Any other condition upon which their MCO and the out-of-network provider agree
The member must contact the MCO and make a request for continuity of their previous care. The time limit for the services from an out-of-network provider for all conditions above except for pregnancy. For pregnancy, the time limit lasts through the pregnancy and the first visit to a health care provider after the baby is born. Maryland Insurance Administration Continuity of Health Care Notice
Coverage for Pregnant Members If you are eligible, Medicaid will cover your medical expenses during your pregnancy and for a year after your baby is born. Medicaid is free and has no co-pays or deductibles for pregnant members. Visit the Pregnancy Coverage page for more information.
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| Discover HealthChoice | Managed Care Organizations | Managed Care Organizations (MCOs) are healthcare organizations that provide 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.
If you do not choose an MCO when you enroll in HealthChoice, the State will automatically assign you to an MCO.
Participating Managed Care Organizations
Members 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 individuals with intellectual disabilities (ICF-IDD) Are in Model Waiver Program Are already in a long term care facility or are expected to need more than 90 days of care 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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| Discover HealthChoice | Programs | HealthChoice provides a large variety of programs to members to promote healthy living and wellness.
Rare and Expensive Case Management (REM) Program Case managed fee for service for recipients with specified rare and expensive conditions
Healthy Kids Program The Program provides assessments and targeted interventions to enhance the quality of health services to eligible recipients less than 21 years of age.
Maryland Healthy Smiles Dental Program Dental services will be available to all adults over the age of 21 who receive full Medicaid benefits, effective January 1, 2023
Employed Individuals with Disabilities Program The Program provides Medicaid to working Marylanders with disabilities who meet a few conditions.
Home and Community-Based Services These are services that enable children and adults to remain with their families and participate in community activities while receiving needed health care.
Behavioral Health Inpatient and outpatient behavioral health services are a comprehensive array of services and supports to help individuals with substance use disorders, mental health disorders, co-occurring disorders, and problem-gambling disorders recover. | 4 |
| Accordion Name : HealthChoice (12)
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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.
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| HealthChoice | Participating HealthChoice MCOs | | 3 |
| 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
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| 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
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| 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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