What are the differences between Medicaid HealthChoice managed care and fee-for-service behavioral health services and related pharmacy benefits?
Maryland Medicaid provides primary behavioral health care—such as assessment and treatment for mild depression or anxiety—separately from specialty behavioral health services, like treatment for serious mental illness or substance use disorders. This separation, called a “carve-out”, ensures that patients can access general behavioral health care through their primary care provider and receive specialized care from providers with specific expertise.
Primary care providers may evaluate and treat primary behavioral health for both Medicaid managed care and fee-for-service patients within the scope of their practice.
Managed Care Primary Behavioral Health Services
In managed care, Medicaid HealthChoice members receive primary behavioral health services through their managed care providers. The managed care organization pays the provider directly for medically necessary covered services.
Providers must enroll with Medicaid through
ePREP and participate with the patient’s managed care organization to receive payment for services.
Fee-For-Service Specialty Behavioral Health Services
Medicaid specialty behavioral health services are “carved out” of managed care. Maryland Medicaid manages these services and pays the provider directly. This is known as fee-for-service. This means the provider receives payment for each service based on Maryland Medicaid’s fee schedule.
All Medicaid members, which include HealthChoice managed care members, and providers work with our behavioral health administrative services organization,
Carelon, to access medically necessary covered specialty behavioral health services.
In order to receive payment for services, behavioral health specialists must complete
both of the following steps:
- Enroll with Medicaid through ePREP and
- Register with Carelon.
Related Pharmacy Benefits
Most behavioral health-related medications are “carved-out” of managed care. The Maryland Medicaid Fee-for-Service (FFS) Pharmacy Program processes these prescription claims.
For behavioral health medications available to both Medicaid HealthChoice managed care and fee-for-service patients, see the Medicaid Pharmacy Program.
