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HealthChoice

What is a Managed Care Organization (MCO)? 

  • An MCO is a healthcare organization that provides services to Medicaid recipients by contracting with a network of licensed/certified healthcare providers.
  • All MCOs are responsible to provide or arrange for a wide array of healthcare services. The services and the MCOs responsibilities are described in the HealthChoice MCO Provider Agreement.
 
Call the HealthChoice Help Line at 1-800-284-4510, if you
  • Have questions about HealthChoice benefits
  • Have problems getting services from your MCO
  • Have questions about services that are not covered by the MCO but may be covered by Medicaid
 
Participating HealthChoice MCOs 
 
For additional information about each of the nine MCOs click on the link above. 
 

How will beneficiaries know if they must enroll in an MCO and choose a Primary Care Provider? 

For those who enroll in Medicaid through Maryland Health Connection 

  • Log into your account www.marylandhealthconnection.gov; or
  • Download Maryland Health Connection’s free mobile app, Enroll MHC; or
  • Call Maryland Health Connection at 1-855-642-8572
 
Those that go through the Department of Human Services (DHS) for their Medicaid eligibility: 
  • Call Maryland Health Connection at 1-855-642-8572; or
  • Complete the form you received in your enrollment toolkit and mail in.
 
If you do not choose an MCO the State will automatically assign you to an MCO.
 
For additional information, click HealthChoice Enrollment  
 

Who is not eligible to enroll in an MCO? 

Medicaid beneficiaries are not eligible for HealthChoice if they:
  • Are on Medicare
  • Are 65 years or older
  • Are only eligible for Medicaid under spend down
  • Are in program with limited benefits such as the Maryland Family Planning Program
  • Are in an intermediate care facility for mentally retarded persons (ICF-MR)
  • Are in Model Waiver Program
  • Are already in a long term care facility or are expected to need more than 90 days of stay
  • Have been in an institution for mental disease (IMD) for 30 days.
  •  Are eligible for the Rare and Expensive Case Management (REM) Program and have elected to enroll in REM 

 

 What services are provided under the HealthChoice program?

All HealthChoice MCOs must cover basic health care benefits such as:
 
• Visits to the doctor, including regular check-ups
• Healthy Kids check-ups including immunizations
• Prescription drugs (No pharmacy copays for children under 21 & pregnant women)
• X-ray and lab services
• Urgent care center services
• Emergency services (also covered out of state)
• Hospital services
• Well women care
• Prenatal and postpartum care
• Family planning and birth control (No pharmacy copays)
• Home health services
• Vision exam & glasses for children under 21
• Hearing Aids
• Dental care for children under 21 and pregnant women – Call the Maryland Healthy Smiles Dental Program, at 1-855-934-9812 
 

What other services do MCOs provide?

Other services related to the patient’s healthcare such as:
• Outreach and home visits for certain special needs and hard-to-reach populations
• Case management for special populations
• Disease Management for chronic conditions
• Assistance with coordinating transportation through the local health departments and limited transportation assistance to medical appointments
• Health care providers are required to provide language interpretation.
• Most MCOs offer limited adult dental services.
• Most MCOs offer limited over the counter drugs.
 

Are long term care services provided?

If a Health Choice beneficiary requires more days in a long term care facility than is covered by the MCO (currently 90 days or less) they must apply for Medicaid long term care (LTC) benefits.  LTC eligibility requirements are more restrictive than HealthChoice.
 
  

What are the additional HealthChoice benefits that are covered by Medicaid and that are not covered by MCOs?

 • Behavioral health services
-specialty mental health services like counselors, psychologists, psychiatrists
-  substance use disorder treatment and recovery services      

Beacon Health

• Outpatient physical therapy, speech therapy, occupational therapy services for children under 21
• Personal care services – Medical day care services for adults or children
• Special support services for individuals with developmental disabilities under the Developmental Disabilities (DD) Waiver
• Health related services and targeted case management services provided to children under the child’s Individualized Education Plan (IEP) or Individualized Family Service Plan(IFSP)
• Viral load testing services, genotypic, phenotypic, or other HIV/AIDS drug resistance testing and HIV/AIDS drugs
• Non- emergency medical transportation services may be available through the local health department

LHD Transportation     

What is the REM Program?

 The Rare and Expensive Case Management (REM) program is a case managed fee-for-service alternative to HealthChoice Managed Care Organization (MCO) participation for recipients with specified rare and expensive conditions. 
 
Criteria for Participation: A person must be eligible for HealthChoice in order to receive REM services. Also, the REM Program is limited to individuals with certain qualifying conditions or diseases. Information regarding these diseases may be obtained by calling 1-800-565-8190.
 

When can a HealthChoice member go to an out-of-network provider without a referral? 

  • Check with the MCO. Each MCO has rules about when a referral is needed for specialty care and most MCOs require all services to be obtained from providers in network.
  • HealthChoice does not cover services when a member is out of state except for emergencies.
 

There are a number of services that MCOs are responsible to cover even when the provider is not in the MCOs network. These are called self-referred services and include: 

  • Emergency services
  • Family planning services
  • Services provided by school-based health center services ervices provided by school-based health center services
  • Pregnancy-related services initiated prior to MCO enrollment
  • Prenatal, intrapartum, and postpartum services performed at a free-standing birth center located in Maryland or a contiguous state
  • Newborn’s initial medical exam in the hospital
  • Child in State supervised care – initial medical exam by EPSDT certified provider
  • HIV/AIDS annual diagnostic and evaluation service visit
  • Renal dialysis services provided in a Medicare certified facility 

Additional Member Right to Use Non-Participating Providers

The Maryland Insurance Administration (MIA) also requires all insurers, including HealthChoice MCOs, to allow members to continue to see a provider under certain circumstances for continuity of care reasons.
  • The member must have one or more of the following types of conditions: 
    1. Acute conditions
    2. Serious chronic conditions
    3. Pregnancy
    4. Any other condition upon which their MCO and the out-of-network provider agree
  • The member must contact the MCO and make the request. 
The time limit for the services from an out-of-network provider for all conditions above except for pregnancy: 
  • 90 days measured from the date the member’s coverage starts under the new plan
 
Or
  • Until the course of treatment is completed
 
For pregnancy, the time limit lasts through the pregnancy and the first visit to a health care provider after the baby is born. 
 

For additional information about HealthChoice: