HealthChoice is the name of the Maryland’s statewide mandatory managed care program. The HealthChoice Program provides health care to most Medicaid participants. Eligible Medicaid participants enroll in a Managed Care Organization (MCO) of their choice and select a primary care provider (PCP) to oversee their medical care.
What is a Managed Care Organization (MCO)?
Managed Care Organizations (MCOs) are health care organizations that provide services to Medicaid recipients in Maryland. These organizations contract with a network of providers to provide covered services to their enrollees. MCOs are responsible to provide or arrange for the full range of health care services. There are currently 7 MCOs participating in HealthChoice:
Information on any or all of the MCOs may be obtained by calling the member services lines of the managed care organizations. (See MCO Member Services).
If you have questions about your coverage, you can also call the HealthChoice Enrollee Help Line at 1-800-284-4510.
How does a participant enroll in an MCO?
Participants can enroll in an MCO and pick their primary care provider (PCP) after they receive information from the enrollment broker about each MCO with directions about how to enroll in an MCO and select their PCP.
How are MCOs reimbursed?
The Medicaid Program makes payments to MCOs at fixed capitation rates. The Capitation Rate methodology is based on Adjusted Clinical Group (ACG) assignment utilizing an enrollee' s past Medicaid claims history record. If there is insufficient data to generate ACG assignment, the Department assigns the enrollee to a geographic/demographic category that reflects the enrollees age, residence, eligibility group, and gender. The eligibility groups are Families and Children, and Disabled. By categorizing recipients based on their utilization of services, the program assures higher payments for the sickest patients. In addition, there are a few special payment categories to MCOs including: a lump sum payment for delivery costs for pregnant enrollees; enrollees under age one; and enrollees with HIV/AIDS.
Who is eligible for HealthChoice?
The HealthChoice Program is mandatory for Medicaid eligibles who qualify, which includes most Medicaid recipients. About 75% of all Medicaid eligibles are in HealthChoice. Any participant who enrolls in Medicaid through Maryland Health Connection, must enroll in HealthChoice.
Who is NOT eligible for the HealthChoice Program?
While most Medicaid recipients are eligible to participate in HealthChoice, due to certain circumstances or conditions of Medicaid eligibility, some are not eligible to be enrolled in an MCO. These recipients include:
- individuals who receive Medicare,
- individuals who are 65 years or older,
- individuals who are eligible for Medicaid under spend down,
- Medicaid recipients who have been or expected to be continuously institutionalized for more than 30 successive days in a long term care facility or in an institution for mental diseases (IMD),
- individuals institutionalized in an intermediate care facility for mentally retarded persons (ICF-MR),
- recipients enrolled in the Model Waiver, and
- recipients enrolled in limited coverage categories, such as women who receive family planning services through the Family Planning Program.
What services are provided under the HealthChoice program?
HealthChoice enrollees receive the same benefits as those available to Maryland Medicaid recipients through the Medicaid fee-for-service system. Under HealthChoice the MCOs contract to provide a specific set of Medicaid-related services. This is referred to as the MCO “Benefit Package”. The services that are not included in the Benefit Package are still available for MCO enrollees and are paid directly by Medicaid. Mental health services are provided by a Specialty Mental Health System administered by the Mental Hygiene Administration.
Services that are not included in the MCO contract but available to MCO enrollees are:
- Health related services and targeted case management services provided to children when the services are specified in the child’s Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP);
- Behavioral health services, including specialty mental health and substance use disorder treatment, are available through the behavioral health system 1-800-888-1965;
- Rare and expensive case management services;
- Personal care services; Medical day care services for adults or children;
- Long term care services (after the first 30 days of care);
- Healthy Start case management services;
- Viral load testing services, genotypic, phenotypic, or other HIV/AIDS drug resistance testing for the treatment of HIV/AIDS;
- Special support services for individuals with developmental disabilities, under the Developmental Disabilities (DD) Waiver;
- Transportation services; and,
- Physical therapy, speech therapy, occupational therapy and audiology services for children under 21 years.
What other services do MCOs provide to those enrolled?
MCOs may offer additional services not in the benefit package to its enrollees but it does not get reimbursed for them. All of the MCOs have chosen to offer preventive dental services for adults, a service not normally covered under Maryland Medicaid. Only those enrolled in HealthChoice may receive these services.
MCOs are responsible for providing other services related to the patient’s healthcare. These other services include: language interpretation, educating enrollees on prevention and good health habits; providing case management, outreach and home visits for certain special needs and hard-to-reach populations; and coordinating needed services such as transportation and the Supplemental Nutritional Program for Women, Infants and Children (WIC).
What are other responsibilities of MCOs?
In addition to providing Medicaid-covered services to those enrolled in the MCO, an MCO has specific standards and responsibilities concerning the provision of certain care. Below is a listing of instances where the MCO has some specified responsibilities.
The MCO is responsible for reimbursing out-of-plan providers for the following services: emergency hospital and professional services; self-referred services which includes specified family planning services, school-based health center services; substance abuse services; pregnancy-related services when a new HealthChoice enrollee has an established out-of-plan provider; initial medical examination for children in State custody; annual HIV/AIDS diagnostic and evaluation visit; renal dialysis; and the initial examination of a newborn by an on-call hospital physician when an MCO does not provide for the service prior to the baby’s discharge.
Students can self-refer for up to 4 visits per semester to school-based health centers (SBHCs) to address acute or urgent service needs. SBHCs must submit medical encounter information to the child's primary care provider within the MCO, so that the provider can provide follow-up treatment if necessary. SBHCs are paid directly by MCOs for the acute and urgent services provided in the SBHCs. SBHCs and MCOs collaborate with each other to ensure that children receive necessary, high quality health care services. SBHCs may also subcontract with an MCO to provide additional services beyond the required self-referral services.
Under certain circumstances, children with special health care needs may require specialty care services from out-of-network providers. The extent to which such services may be self-referred as a matter of right by a special needs child depends on whether or not the condition that is the basis for the child’s special health care needs is diagnosed before or after the child’s initial enrollment.
An MCO must assure adequate provider capacity in all geographic areas that it serves. The geographic access standard in an urban area is 30 minutes travel or within 10 miles of the enrollee' s home. In rural areas, it is 30 minutes travel or within 30 miles of the enrollee' s home.
The Pharmacy access standard in an urban area is 10 minutes travel or within 5 miles of the enrollee' s home. In rural areas, it is 30 minutes travel or within 30 miles of the enrollee' s home.
There is also a specific regulatory requirement for timely notification of appointments for immunizations and other wellness services.
What are MCO standards concerning special needs populations?
MCOs must meet specific standards set forth in the regulations for treating seven special needs populations. These include 1) children with special health care needs; 2) individuals with a physical disability; 3) individuals with a developmental disability; 4) pregnant and postpartum women; 5) individuals who are homeless; 6) individuals with HIV/AIDS; 7) individuals with a need for substance abuse treatment; and 8) children under state supervision.
The general provisions for special needs populations include:
- ensuring that Pediatric and adult Primary Care Providers (PCPs), and specialists are clinically qualified to provide or arrange for specialized services;
- developing referral protocols that demonstrate the conditions under which PCPs will make the arrangements for referrals to specialty care networks;
- coordinating case management as part of enrollee's comprehensive plan of care;
- identifying a special needs coordinator as a point of contact for health services information and referral;
- making efforts to contact and educate enrollees who fail to appear for appointments or who have been non-compliant with a regimen of care; and
- after documented unsuccessful outreach efforts, the MCOs must refer the case of the non-compliant enrollee to the local health department for assistance in returning the enrollee to care.
In addition to these general requirements, there are some specific requirements for each of the special needs populations listed below.
Children with Special Health Care Needs
MCOs must have established protocols for medically necessary and appropriate referrals to specialty care providers for children with special health care needs. MCOs must demonstrate that their provider network for special needs children is adequate to ensure appropriate treatment.
MCOs must provide case management services as appropriate. For complex cases involving multiple medical interventions or social services, or both, the MCO shall convene a multidisciplinary team to review and develop the child's plan of care.
Individuals with a Physical Disability
An MCO must document that its providers are clinically qualified to provide durable medical equipment and assistive technology services. To protect recipients from improper institutionalization in a nursing home, MCOs must assess the individual's needs and MCO's ability to meet these needs in the community with other Medicaid services. A second opinion from the medical director must be obtained as well as approval from the Department before a transfer can be made to a nursing home. An MCO must provide education for the MCOs member services staff, triage staff, and case managers on special communications requirements for individuals with physical disabilities.
Individuals with a Developmental Disability
MCOs must ensure that its case managers have training or experience related to developmental disabilities. MCOs must educate their member service staff, triage staff, and case managers on special communication requirements for individuals with a developmental disability. MCOs must provide qualified interpreters upon enrollee's request. While members of the MCO, recipients in the Developmental Disability Administration (DDA) Waiver will continue to receive support services as alternatives to institutionalization in an Intermediate Care Facility-Mentally Retarded (ICF-MR) through the DDA Waiver, but their health care services will be provided by MCOs. The Specialty Mental Health System (SMHS) will provide mental health services.
MCOs must attempt to identify homeless individuals and link them to the appropriate service provider.
Pregnant and Postpartum Women
An MCO must schedule an appointment for the first prenatal visit and for a postpartum visit within 10 days of request and complete a prenatal risk assessment, using an instrument approved by the Department, and forward this form to Local Health Departments. MCOs must also refer a woman identified as high risk to the Healthy Start Case Management program in the Local Health Department.
An MCO must follow, at a minimum, the American College of Obstetricians and Gynecologists (ACOG) guidelines. MCOs must provide access to providers who are capable of addressing complex maternal and infant health issues, including obstetricians, gynecologists, perinatologists, neonatologists, anesthesiologists, and advanced practice nurses.
An MCO must provide substance abuse treatment for pregnant and postpartum substance abusers within 24 hours of request. In addition, an MCO shall offer nutrition counseling, smoking cessation education, and voluntary HIV counseling and testing. An MCO must refer pregnant and postpartum women, infants, and children under five years of age to the WIC Program. In addition, an MCO must link a pregnant woman with a pediatric provider prior to delivery. MCOs must arrange for the appropriate emergency transfer of pregnant women, newborns, and infants to tertiary care centers.
MCOs must provide access to substance abuse treatment within 24 hours of request; case management services; and intensive outpatient programs capable of addressing comprehensive needs including day treatment that allows for children to be with their mother.
Individuals with HIV/AIDS
For individuals who have HIV/AIDS, MCOs must offer HIV/AIDS case management services at any time after HIV/AIDS diagnosis. An individual who refuses these services can request case management from the MCO at any time. MCOs must ensure that individuals with HIV/AIDS receive case management services that link the enrollee with the full range of available benefits, as well as any needed support services.
Individuals with HIV/AIDS who are substance abusers will receive substance abuse treatment within 24 hours of request. An HIV positive individual can self-refer for an annual Diagnostic and Evaluation Service (DES) visit. The DES consists of a comprehensive medical and psychosocial assessment.
The risk-adjustment system for MCO capitation rates includes a diagnosis-related rate for those with AIDS. Viral load and genotypic, phenotypic or other HIV/AIDS drug resistance testing used in the treatment of AIDS will be on a fee-for-service basis and will not be the responsibility of the MCO. Pediatric AIDS patients (0 to 20 years old) are enrolled in the Rare and Expensive Case Management program and dis-enrolled from the MCO.
Individuals needing Substance Abuse Treatment
Substance abuse treatment is a mandatory covered benefit under the MCO. The benefits include: 1) screening for substance abuse as part of the enrollees initial health screen, initial prenatal screen, or when behavior or physical status indicates the likelihood of substance abuse; 2) a comprehensive assessment following a positive screen; and, 3) a continuum of substance abuse services.
Substance abuse treatment services include: a comprehensive substance abuse assessment; outpatient substance abuse treatment; detoxification treatment either outpatient or inpatient if medically necessary and appropriate; residential addiction programs for children under 21, and for Temporary Cash Assistance Program (TCA) adult parents (21+); For persons with HIV/AIDS and pregnant substance abusing women, MCOs must provide access to substance abuse services within 24 hours of request.
There are new policy changes for substance abuse treatment services for HealthChoice enrollees. The new Substance Abuse Improvement Initiative, effective Jan 1, 2001, enhances customer access to treatment services through a self-referral process, ensures prompt payment of clean claims, and encourages MCOs and their Behavioral Health Organizations (BHOs) to contract with treatment providers.
Children under State Supervision
Children in State supervised care, such as foster care, have 60 days to select an MCO. The MCO that the child is enrolled in must provide or arrange to provide all Medicaid covered services. The MCO must assure continuity and coordination of care, provided locally to the extent possible if a child is temporarily relocated. DHMH will allow for expedited dis-enrollment and reassignment for children in State-supervised care who have had a change in circumstances (example - moved to an area outside the MCOs service area). An MCO must permit self-referral of a child in State supervised care to an initial examination, (including a mental health screen which will be paid for by the Specialty Mental Health System.) An MCO must appoint a liaison to coordinate services for these children to work with the DSS foster care worker.
What is the REM Program?
Under HealthChoice, there is a special program called the Rare and Expensive Case Management Program (REM). Medicaid recipients with specific rare and expensive conditions are eligible for the REM program. A HealthChoice recipient is eligible for REM based on having certain diagnoses. REM participants receive fee-for-service benefits and may receive an expanded set of benefits as outlined in the regulations.
Individuals enrolled in the REM Program are assigned a case manager who: (1) assesses their needs; (2) directs them to appropriate providers; (3) works with multi-disciplinary teams, (4) develops plans of care, (5) monitors clinical care and services, (6) assists in service coordination and family supports, (7) addresses changing clinical and other needs, and, (8) recommends transfers out of the REM Program when appropriate. For additional information, refer to the REM Program under Long Term Care Services.