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The Utah Medicaid agency contracts with managed health care organizations to provide medical and mental health services to Medicaid clients. Medicaid typically pays a monthly fee for each Medicaid client enrolled in a health maintenance organization (HMO) and/ or Prepaid Mental Health Plan (PMHP). Each plan is responsible for all health care services specified in the contract for Medicaid clients enrolled in that plan. Each plan may offer more benefits and/or fewer restrictions than the Medicaid scope of benefits. It must specify services which require prior authorization and the conditions for authorization. The client's Medicaid Identification Card states the name of each plan in which he or she is enrolled. Clients enrolled in an HMO and/or a PMHP must receive all services covered by each plan through that plan. The provider obtains payment from the plan. Typically, each plan requires a provider to be affiliated and follow its coverage and authorization requirements. All questions concerning services covered by and payment from an HMO or PMHP must be directed to the appropriate plan. More information is available through publications in English and in Spanish. Topics discussed in the remainder of this document include: Verifying Coverage ; Medical, Pharmacy and Dental Services; Mental Health Services; Emergency Services ; Fee For Service Coverage; Complaints and Grievances; Medicaid Manual References It is critical for all Medicaid clients to show their Medicaid Identification Card to every provider BEFORE receiving any type of service. Medicaid assures coverage ONLY when the provider is enrolled as a Utah Medicaid Provider AND agrees to accept the Medicaid payment as payment in full. It is critical for all providers to verify Medicaid coverage BEFORE services are provided. Providers must know if the client is eligible for Medicaid on the date of service and whether the client is enrolled in an HMO, in a Prepaid Mental Health Plan, in the Restriction Program, or has a Primary Care Provider. This information is printed on the client's Medicaid card, and the information is also available through Medicaid Online, Access Now and Medicaid Information. Note:
Medicaid staff make every effort to provide complete and accurate
information on all inquiries. However, because information regarding
eligibility and the plan the client must use is available to providers
electronically, a claim will not be paid even if the information
given to a provider by Medicaid staff was incorrect. An HMO is responsible for all medical services as set forth under Title XIX of the federal Social Security Act, Title 42 of the Code of Federal Regulations (CFR), and the Utah Administrative Code, Rule R414-1-5, Services Available. In most areas of the state, mental health services are provided ONLY through a Prepaid Mental Health Plan (PMHP). Medicaid clients who live in certain counties of the state must receive mental health services from community mental health centers which have contracted with the Medicaid agency as a PMHP. Physicians or psychologists treating individuals who may become eligible for Medicaid should contact the appropriate PMHP to ensure payment or arrange for the patient to be transferred to the contracting mental health center for continued services. Providers who render emergency care must obtain approval from the PMHP within 24 hours of service. The provider will be reimbursed only when he or she has made a good faith effort to obtain the required approval within 24 hours of providing emergency services. Refer to the Mental Health Provider Manual for more information about services covered under the PMHP, exceptions for children in state custody, and the transition from a private practitioner to a Prepaid Mental Health Plan. RETURN TO TOP OF PAGE Emergency Services for Clients in an HMO Managed
care plans are responsible for covering all emergency services for
enrollees, regardless of where the emergency occurred and was treated.
Federal regulations 42 CFR §447.53(b)(4) state emergency services
are services provided in a hospital, clinic, or other facility that
is equipped to furnish the required care, after the sudden onset
of a medical condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) so that the absence of immediate
medical attention could reasonably be expected to result in one
of these three conditions: Providers
who render emergency care to a patient enrolled in a managed care
plan must obtain approval from the plan within the time frame specified
by the plan, which is usually within 24 hours of service. The provider
will be reimbursed only when the provider has made a good faith
effort to obtain approval from the plan within the time frame specified.
Each health maintenance organization (HMO) and Prepaid Mental Health
Plan (PMHP) cover services as stated in the contract with Medicaid.
Each plan has its own procedures for services that require prior
authorization. Each plan may offer more benefits answer restrictions
than the Medicaid scope of benefits. Services covered by Medicaid, instead of the managed care plan, vary according to the individual contracts with managed care plans. For example, HMO contracts do not include pharmacy or dental services. Medicaid refers to services not covered in a contract with an HMO or Prepaid Mental Health Plan as 'carve-out' services under fee for service coverage. Fee-for-service
clients may receive covered services from any Medicaid provider.
The provider must follow Medicaid coverage and prior authorization
requirements. The provider submits the claim to and obtains payment
from Medicaid. All questions concerning services covered by Medicaid
and not covered by the managed care plan should be directed
to Medicaid Information. For example, a Medicaid client enrolled
in an HMO which does NOT cover pharmacy services may receive services
at any pharmacy which is enrolled with and accepts Utah Medicaid
Program coverage. Complaints and Grievances: Complaints and grievances concerning an HMO from either a client or a provider must first go through the HMO's complaint process. Clients who have a problem with services, such as not getting the services needed, not being able to see a provider in a timely manner, not being satisfied with the quality of the service received, should first contact the member representative for the HMO or Prepaid Mental Health Plan with which he or she is enrolled. If the problem is not resolved, ask how to file a grievance. In most cases, the client must write a letter to the HMO or Prepaid Mental Health Plan explaining the problems. Clients: After the grievance process, if you are still not satisfied with the way the problem is handled by the HMO or Prepaid Mental Health Plan, call Medicaid Information. (In the Salt Lake City area, call 538-6155. In other areas of Utah, call toll-free 1-800-662-9651.) Tell the Customer Service Representative you have a problem with services received (or not received). Say whether it is a problem with an HMO or with a Prepaid Mental Health Plan. The representative will transfer you to a staff person who can discuss the problem with you. You also have the right to file for a Fair Hearing after you have completed the grievance process with the managed care plan. If you are still not satisfied with the HMO's final decision, you may then contact the Division of Health Care Financing and request a hearing. References:
Refer to the Utah
Medicaid Provider Manual, Section 1,
for more information
about the following subjects: (Please be patient. SECTION 1 takes
a minute to load.) Information about managed care plans on the national level is available on the Internet at http://cms.hhs.gov |
Last edited June 4, 2008