Clarifying Purpose of Medicaid Information Bulletin

Medicaid Information Bulletins and Provider Manuals advise providers as to scopes of service, policies, procedures and processes in the Utah Medicaid Program for 'fee-for-service' Medicaid clients.  A fee-for-service Medicaid client is defined as either of the following:

1.The client is not enrolled in a managed care plan (MCP); or 

2.The client is enrolled in a managed care plan, but the service that is needed is covered by Medicaid, not by the plan.

Services covered by Medicaid, instead of the managed care plan, vary according to the individual contracts with managed care plans.  For example, some MCP contracts do not include pharmacy and/or dental services.  Medicaid refers to services not covered in a contract with a MCP or Prepaid Mental Health Plan as 'carve-out' services.

Fee-For-Service Clients

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 pharmacy services from any Medicaid pharmacy provider.

Medicaid Restricted Program

Different rules apply to clients enrolled in the Medicaid Restricted Program.  Restricted Program clients are assigned to a Primary Care Physician or MCP, and to a particular pharmacy. These clients must receive all health care services through either the assigned provider or MCP, or receive a referral from those providers, and all pharmacy services from the assigned pharmacy.

Managed Care Plan Enrollees

Medicaid contracts with managed health care organizations to provide medical and mental health services to Medicaid clients.  Each MCP and Prepaid Mental Health Plan covers services as stated in the contract with Medicaid, and each has its own procedures for services that require prior authorization.  Each plan may offer more benefits and/or fewer restrictions than the Medicaid scope of benefits.

Clients enrolled in a MCP and/or a Prepaid Mental Health Plan (PMHP) must receive all services covered by each plan through that plan.  Providers must be affiliated with the managed health care plan and follow its coverage and authorization requirements.   The provider obtains payment from the health care plan.

All questions concerning covered services and payment from a MCP must be directed to the appropriate plan.  A list of MCPs and PMHPs with which Medicaid has contracts is included with your provider manual.

Verifying Coverage

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, if 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 Access Now and Medicaid Information.  Eligibility and MCP enrollment may change from month to month.

Note: Medicaid staff make every effort to provide complete and accurate information on all inquiries.  However, because information regarding the plan the client must use is available to providers, a claim will not be paid even if the  information given to a provider by Medicaid staff was incorrect.

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.  If the individual who initiated the complaint is not satisfied with the MCP's final decision, he or she may then contact the Division of Medicaid and Health Financing and request a hearing.

References

Please 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