Medicaid Letters: Medicaid & Managed Care

What is managed care?

    Managed care providers are commonly known as Health Maintenance Organizations or “HMOs”. In a managed care plan you must select a primary care physician from those available in the plan. This physician will coordinate all your care and make any referrals you may need to a specialist.

How do I know what an HMO provides?

    Every HMO plan must give you specific information, usually in a member handbook, about topics such as: what services are covered, prior authorization requirements, emergency services, payment for unauthorized services and grievance procedures.

If I am on Medicaid, do I have to join a managed care plan?

    Erie County now has a mandatory managed care plan for most Medicaid recipients. However, there are a few exceptions. You must have a choice of at least two different HMOs and at least three difference primary care physicians, they must be geographically accessible and be able to provide care for you without a language barrier.

Who is exempt from mandatory managed care?

    Certain people are exempt from mandatory enrollment; they can voluntarily join, but do not have to.

  • If you are pregnant and have an established relationship with a comprehensive prenatal primary care provider who is not part of the managed care provider network, you can have your mandatory participation delayed until 60 days after the birth of your child. This allows you to keep your present doctor through your pregnancy.
  • The managed care plan cannot help you in your own language.
  • If you have a chronic medical condition that is being treated by a specialist physician who is not a part of the managed care network, you may be exempt from mandatory managed care.
  • You have good cause for not wanting to enroll.

Is managed care automatically exempt for anyone?

    Yes, some people are automatically exempt. If you are a Medicaid recipient in the following categories you can but do not have to participate in managed care:

  • Native Americans;
  • persons in alcohol or substance abuse residential programs for the mentally retarded;
  • those with developmental or physical disabilities receiving home and community-based services or care-at-home services;
  • persons receiving services provided by an intermediate care facility for the mentally retarded;
  • Medicaid/Medicare dually eligible individuals.

Is anyone ineligible or prohibited from managed care?

    Yes. If you are a Medicaid recipient in the following categories you cannot participate in managed care:

  • you are an infant living with an incarcerated mother;
  • you are in Medicaid’s restricted recipient program;
  • persons receiving services from long-term home health care programs, state-operated psychiatric facilities, or residential treatment facilities for children;
  • persons expected to be eligible for Medicaid for less than six months;
  • persons on Medicaid only for tuberculosis treatment;
  • blind or disabled children living apart from parents for 30 days or more;
  • residents of nursing facilities at the time of enrollment;
  • persons receiving hospice services;
  • foster children;
  • persons with medical or health care coverage available from another party such as a spouse;
  • you get Medicare and are in a demonstration program for long term care.

Are all Medicaid services available through managed care?

    No. A few services will still be provided outside of managed care programs, especially for the developmentally disabled. Day treatment services, long term services and comprehensive case management services to individuals with developmental disabilities will continue to be provided through Medicaid.

    Also, TB directly observed therapy, AIDS adult day health services and HIV COBRA case management will be provided to Medicaid recipients, but not through managed care programs.

What if I need to see a specialist and the managed care provider does not have one available?

    You have a right to receive Medicaid-covered health services from “out-of-plan providers” (physicians not in your HMO) if your managed care plan does not provide such services. But your primary care physician must give you an approved referral or else you may be responsible for payment.

What if I need emergency care?

    All managed care providers must provide for emergency services for medical necessities. Medical necessities are conditions that the average person would expect to result in serious damage to their health if not treated immediately.

What if I have a problem with my managed care provider?

    All HMOs are required to establish grievance procedures for any complaints or disputes you have, and utilization review for any questions about the medical necessity of services or procedures you or your doctor request.

What is a grievance procedure?

    A grievance is any complaint you have with your managed care plan, such as if your plan refuses to pay for coverage of a medical service such as a blood test. You can file a grievance any time your plan denies a request for a referral or claims a benefit is not covered.

How do I file a grievance?

    Your plan must explain how to file a grievance. In many cases you can file grievances over the phone. Your plan must have an 800, toll free, grievance number, staffed with real people (not a machine) at least 40 hours per week. Sometimes you may be requested to make your grievance in writing.

When will a decision be made on my grievance?

    You must receive written acknowledgment of the grievance within 15 business days of filing the complaint. Your grievance must be decided within:

  • 48 hours if the delay would significantly increase the risk to your health;
  • 30 days after the receipt of all necessary information when the issue involved request for a referral or a denial of benefits;
  • 45 days in all other cases, such as billing disputes.

When you call or send in your grievance, make sure you ask what, if any, additional information is needed to make a decision so that your grievance is not unnecessarily delayed.

How will I receive the decision?

    You must be notified by telephone of a decision within 48 hours and in writing within 3 business days. The decision must explain the reason for the decision, any clinical basis for the decision and how to appeal if you disagree.

How can I appeal?

    If you disagree with the grievance decision, you can appeal within 60 days of the date you received the decision. Appeals must be in writing. Your appeal must be resolved within 30 business days or within 2 business days when a delay would significantly increase the risk to your health.

Can anything happen to me or my doctor for filing a grievance?

    No. The law prohibits managed care plans from punishing patients or doctors who file grievances. Your managed care provider will keep a record of all grievances and appeals, but this and all other patient data are kept confidential.

Do I have any other options?

    While you are using the grievance and appeal procedures set up by your HMO, you can also apply for a Fair Hearing and receive aid continuing. You do not have to use your managed care plan’s procedures first before seeking a remedy through a Fair Hearing.

What is Utilization Review (UR)?

    Utilization Review is very similar to a grievance, except it is for questions regarding the “medical necessity” of a requested service or procedure.

Example: Monica discovered a lump in her breast. Her doctors performed a mastectomy, but her managed care provider refused to pay for any cosmetic reconstruction because such reconstructive surgery was not “medically necessary.” Monica and her doctor can request that the managed care provider conduct a utilization review to determine whether or not they should pay the bill for her reconstructive surgery.

When should I use the grievance rather than the utilization review procedure?

  • when your managed care provider refuses to pay for services that you received from a provider outside of your HMO network or without a proper referral from your primary care physician
  • when your managed care provider made a mistake in classifying your case
  • when you want to challenge coverage or payment issues that are not about whether the service or treatment plan is medically necessary.

When can I request a Utilization Review?

    You can ask for a UR either before, after or during your course of treatment. Your HMO must tell you how to file UR requests any time it refuses to provide a service because it is not medically necessary.

When will I receive a decision?

    You will receive a UR decision after the receipt of all necessary information within:

  • 1 business day if the services involve continued or extended health care
  • 3 business days if the services require pre-authorization
  • 30 days if the health care services have already been received.

An “adverse determination”, meaning the request is not medically necessary, must be in writing and contain the clinical reason for the decision.

What if I have an emergency?

    You are not required to go through UR or get “prior-authorization” to use the emergency room, but your managed care provider may refuse to pay for emergency services that they believe are not medically necessary.

Can I appeal a Utilization Review decision?

    Yes. Your decision must include the procedures for filing an appeal. Appeals must be made within 45 days of a UR decision and you must receive a decision on your appeal within 60 days of filing.

Can an appeal decision be made quickly?

    If your appeal involves a determination about continued or extended health care services, procedures or treatments or additional services if you are undergoing a course of continued treatment prescribed by a physician, you can receive an “expedited appeal” that must be resolved within 2 business days.

Do I have any other options?

    While you are using the UR and appeal procedures set up by your HMO, you can also apply for a Fair Hearing and receive aid continuing. You do not have to use your managed care plan’s procedures first before seeking a remedy through a Fair Hearing.


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