Therese McIntyre

Communications and Legislative Affairs Director

What is HealthChoice?

HealthChoice is Maryland’s statewide Medicaid managed care program that began in 1997 by an 1115 Waiver.

The HealthChoice program provides health care to most Medicaid and Maryland Children’s Health Program (MCHP) enrollees.

Who is eligible for HealthChoice?

Most Medicaid/MCHP recipients are eligible and must be enrolled in HealthChoice. Examples of people who are not eligible are:

• Dual eligibles – those who have Medicare and Medicaid• Children in an out-of-state placement• Children and adults who enroll in the Rare and

Expensive Case Management Program or REM

How do clients enroll in HealthChoice?

• The person must be determined eligible for MCHP or Medicaid to enroll

• HealthChoice eligible clients will be sent an enrollment packet regarding each health plan available where they live

• The enrollment packet contain information on each plan including any “extra” benefits that might be available

What health plans does HealthChoice offer?

Amerigroup Coventry Healthcare Diamond Plan Helix Family Choice, Inc. Jai Medical Systems Maryland Physicians Care Priority Partners United Health Care

Does it make a difference which health plan they choose?

Yes! Each plan has its’ own network of doctors, hospitals, pharmacists, and dentists. Enrollees can only receive care from providers in the health plan’s network.

Some health plans offer additional benefits like adult dental services. Dental services are covered in full for children and pregnant women.

How long do consumers have to make a health plan choice?

• Most consumers have 21 days from the date of their MCHP or Medicaid eligibility notification

• If the recipient is a child in foster care or formal kinship care, they have 60 days to choose a plan.

Encourage consumers, particularly those with special needs, to carefully think about their plan choice and choose a plan.

If they don’t choose a plan, the State will choose one for them and…

they won’t be able to change the plan for a year!

What if they need medical care before they choose a health plan?

• All Medicaid/MCHP recipients are issued a fee-for-service Medicaid card, the “red and white card”.

• Consumers should use this card until they receive their HealthChoice health plan member card.

Important: Consumers should keep the “red and white card” for self-referral services even after they receive their health plan member card.

Should consumers choose their primary care provider when they choose their health plan?

• Yes! Consumers should select their (or their child’s) primary care provider (PCP) when they choose a health plan. This doctor provides routine care and must make referrals for any needed specialty care.

• Within 10 days consumers should receive a member handbook and a member card. The PCP they chose should be listed on the back of the card. They should check that the correct doctor is listed.

How do consumers enroll in HealthChoice?

They can call 1-800-977-7388

Or…

Simply mail back the form that came with their packet

What benefits are available to HealthChoice enrollees?

• HealthChoice health plans must provide a complete benefit package that is the same as the benefits that were available to under the fee-for-service system.

• Some services are “carved-out” and are not the health plan’s responsibility. Consumers access these services with their “red and white card”.

Covered Services Include:

Inpatient and outpatient hospital care Physician care Laboratory and x-ray services Nursing home and home health care Disposable Medical Supplies and Durable Medical Equipment Services for children under early and periodic screening, diagnosis,

and treatment program (EPSDT) Clinic services Prescription drugs Dental care

What services are “carved out”?

Mental Health Services – this care is accessed through MAPS-MD – 1-800-888-1965

Occupational and physical therapy, speech and language, and hearing services for children and young adults up to age 21

School health services

Family planning

Some HIV/AIDS services

Renal dialysis services

What consumer protections are there for HealthChoice enrollees?

What consumer protections are there for HealthChoice enrollees?

Travel Times

Recipients must have access to primary care services (including obstetrics/gynecology), diagnostic laboratory services, and pharmacy services within a reasonable distance from their home.

What is reasonable?

Urban areas - 30 minutes travel time from the recipient's home or within a 10-mile radius

Rural areas - within 30 minutes travel time or within a 30-mile radius.

Appointments

New HealthChoice enrollees - within 90 days - 15 days if the recipient is high risk as determined by the health risk assessment

Well-child visits - 30 days of the request

Routine and preventative primary care visits - 30 days of the request

Routine specialist visits - 30 days of request (sooner if the primary care provider believes it is necessary)

Urgent care visits - 48 hours of the request

Dental, optometry, lab, and X-ray appointments – 30 days of the request (48 hours if the need is urgent)

Waiting Times

Enrollees arriving on time or early for regular office visit appointments may not be allowed to wait more than one hour before being seen

Health plans may not leave an enrollee’s call on hold for more than 10 minutes

Health plans must respond within 30 minutes to inquiries about the use of the emergency room

General Protections

HealthChoice child and pregnant women enrollees may not be charged any co-payments, premiums, or cost sharing of any kind

Limitations on covered services do not apply to children under age 21 receiving medically necessary treatment

An enrollee’s PCP is responsible for making the determination, based on the health plans referral requirements, of whether or not a specialty care service is medically necessary and appropriate.

General Protections

Health plans must authorize requests for hospitalization, outpatient services, and any testing within 72 hours

Qualified interpreters must be provided at no charge upon request to enrollees who are hearing impaired or who speak limited English.

Durable Medical Equipment (DME) and Disposable Medical Supplies (DMS)

DMS and DME must be authorized by the health plan within 72 hours.

If there is an urgent medical need DMS and DME shall be provided within 24 hours.

For most requests, DMS and DME must be provided within 7 days.

Emergency Services

Under Federal regulations, a health plan may not require pre-authorization for an emergency room visit. Emergency services are defined as health care services that are provided in a hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in:

• Placing the patient's health in serious jeopardy;

• Serious impairment to bodily functions; or

• Serious dysfunction of any bodily organ or part.

Emergency Services

A health plan representative shall respond to patient inquiries as to whether or not to use emergency facilities within 30 minutes.

Emergency Services

Health plans must pay for emergency medical treatment when:

They meet the definition provided in the previous slide – basically this is the the federal Emergency Medical

Treatment and Active Labor Act (EMTALA)

The health plan authorized, referred, or otherwise allowed the enrollee to use the emergency facility or

The health plan fails to provide 24-hour access to the care

needed.

Pharmacy

The health plan must maintain a drug formulary that is at least equivalent to the State’s Medicaid drug formulary as of February 1, 1996.

The health plan must continually update the formulary to add drugs that are equivalent to new drugs approved by the FDA. (If a generic equivalent drug is not available, new brand name drugs rated as P (priority) by the FDA will be added to the formulary.)

Health plans must authorize pharmacy requests within 72 hours

Dental and Orthodontics

Health plans are required to provide the following services to enrollees under age 21:

Emergency, preventive, diagnostic, and treatment services

For children who are at least 3 years old, cleanings twice a year, fluoride treatment, and examination

Sealants for permanent teeth that are without restoration or decay

Orthodontic care when the condition causes dysfunction and the case scores at least 15 points on the Handicapping Labio-Lingual Deviations Index No. 4

General anesthesia during dental procedures when it is medically necessary and appropriate.

Substance Abuse Services

Health plans must provide substance abuse services to their members in a timely manner so as not to adversely affect the health of the enrollee.

Authorizations should occur within 72 hours unless care is needed sooner.

Recipients can self-refer for substance abuse services.

Health plan members younger than 21 years old are eligible for residential substance abuse treatment in an intermediate care facility-alcoholic (ICF-A)

Transportation

Transportation services are typically provided through local health departments, however health plans also have some responsibilities for assisting recipients with transportation concerns. Health plans are required to contact the local health department on behalf of the recipient when needed.

Vision Services and Eyeglasses

For individuals under age 21 the health plan must provide at least one eye examination every year in addition to any vision screen performed as part of an EPSDT screen

Eyeglasses are limited to one pair per year unless lost, stolen, broken, or no longer vision appropriate.

Contact lenses are to be provided if medically necessary and appropriate and if eyeglasses are not medically appropriate for the condition.

Children with Special Health Care NeedsSpecial Protections

Who is the child with special health care needs?

HealthChoice regulations provide a definition of children with special health needs. By regulation these children must be assigned an health plan case manager if requested.

A child with a special health care needs means an individual younger than 21 years old, regardless of marital status, suffering from a moderate to severe chronic health condition:

• With significant potential or actual impact on health and ability to function;

• Which requires special health care services; and

• Which is expected to last longer than 6 months.

PCP’s and specialists serving children with special health care needs in HealthChoice must have experience in treating CSHCN, interdisciplinary medical management, and understand the relationship between somatic and behavioral health care issues and interventions.

A child who is functioning one third or more below chronological age in any developmental area, must be referred for specialty care services intended to improve or preserve the child’s continuing health and quality of life, regardless of the services’ ability to effect a permanent cure.

Physical therapy, occupational therapy, audiology services, and speech and language therapy do not require a referral from the PCP or the MCO. Recipients may access service from any participating provider.

Rare and Expensive Case Management Program (REM)

The REM program is not mandatory. Children and qualified adults may be enrolled in a health plan at the parent's or consumer's request.

Intensive case management services are provided under the REM program to assist with development of a plan of care and coordination of care

Benefits under the REM program include all services available to HealthChoice recipients

Rare and Expensive Case Management Program (REM)

Optional services as approved by the recipient’s case manager may include:

Assisted living

Community Support including respite care and supported employment

Assistive equipment including specialized medical equipment and emergency call systems

How can BHCA help consumers with HealthChoice?

We can help consumers get the health care services they need by:

• Helping them find a PCP or specialty provider

• Providing education on how to use their health plan including how to get needed specialty care

• Providing information on what benefits are available

• Helping to explain their rights if a service or care they need is denied