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MANAGED
CARE PLANS
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 Managed Care Plan (MCP)
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 a MCP 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 a MCP 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
Verifying
Medicaid Coverage
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 a MCP, 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.
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Medical
Services
A
MCP 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.
Mental
Health Services
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
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Emergency
Services for Clients in a Managed Care Plan
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:
1. Placing the patient's health in serious jeopardy;
2. Serious impairment of bodily functions; or
3. Serious dysfunction of any bodily organ or part.
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 Managed Care Plan (MCP) 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.
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Fee
For Service Coverage
Services
covered by Medicaid, instead of the managed care plan, vary
according to the individual contracts with managed care
plans. For example, MCP contracts do not include pharmacy
or dental services. Medicaid refers to services not covered
in a contract with a MCP 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 a MCP which does
NOT cover pharmacy services may receive services at any
pharmacy which is enrolled with and accepts Utah Medicaid
Program coverage.
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Complaints
and Grievances:
Complaints
and grievances concerning a MCP from either a client or
a provider must first go through the MCP'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 MCP 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 MCP 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 MCP or Prepaid
Mental Health Plan, call Medicaid
Information. (In
the Salt Lake City area, call 801-538-6155. 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 a MCP 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 MCP's final decision,
you may then contact the Division of Medicaid and Health
Financing and request a hearing.
References:
Refer to the Utah Medicaid
Provider Manual, Section 1, for more information
about the following subjects:
-
Capitated managed care plans, Chapter 2
- Services available, Chapter 3
- Restriction Program, Chapter 3 - 2
- Verifying eligibility, Chapter 5
Information
about managed care plans on the national level is available
on the Internet at
http://cms.hhs.gov
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