Part 1: Medicaid

Most Medicaid services are called “state plan services.” DHHS publishes policies on all the services it provides through its program. These policies and procedures explain who is eligible, set the qualifications for providers, outline specific rules for services, and detail the process for approving or denying services.

The State provides the following services to Medicaid beneficiaries who are within a full benefits Medicaid category:

  • Inpatient Hospital Services*
  • Outpatient Hospital Services
  • Rural Health Clinic Services*
  • Federally Qualified Health Center Services*
  • Laboratory And X-Ray Services*
  • Nursing Facility Services*
  • Early And Periodic Screening, Diagnostic, And Treatment (EPSDT) Services*
  • Family Planning Services*
  • Tobacco Cessation Counseling for Pregnant Women
  • Physician Services*
  • Home Health Services, including Durable Medical Equipment (DME)*
  • Nurse Midwife Services*
  • Certified Pediatric and Family Nurse Practitioner Services
  • Freestanding Birth Center Services*
  • Transportation To Medical Care (Non-Emergency Medical Transportation, NEMT)*
  • Other Licensed Practitioner Services, including Podiatry, Optometry, Chiropractory*
  • Clinic Services*
  • Dental Services*
  • Physical Therapy*
  • Occupational Therapy*
  • Speech, Hearing, And Language Disorder Services*
  • Prosthetics*
  • Eyeglasses*
  • Prescribed Drugs*
  • Other Diagnostic, Screening, Preventive, and Rehabilitative Services*
  • Services For Individuals Aged 65 Or Older in An Institution for Mental Disease*
  • Services In an Intermediate Care Facility for Individuals with Intellectual Disability*
  • Inpatient Psychiatric Services for Individuals Under Age 21*
  • Hospice
  • Case Management*
  • TB-Related Services*
  • Program of All-Inclusive Care for the Elderly (PACE) services

*Each service has limitations that may apply                 

Case Management

Case management is available to people on Medicaid and to people on some HCBS waivers. They aim to help people with disabilities or chronic conditions access the services they need to live in the community. Case management has four major elements: assessment, care planning, referral and linkage, and monitoring and follow-up.

Assessment

This process focuses on identifying a person’s needs. An assessment should include the following information, as appropriate:

  • Level of functioning
  • Medical and emotional status
  • Familial support
  • Living environment
  • Financial status
  • Educational or vocational placement
  • Community involvement
  • Socialization needs

Case managers may collect information from other sources, such as family members and medical providers. The case manager must finish the assessment and create a support plan within 60 days of enrollment in a waiver. This includes a face-to-face contact in your home.

Care planning

Care planning uses information from the assessment to find services that meet a person’s needs and goals. It results in a case management support plan that includes:

  • Personal information
  • Identification of needs
  • Strengths and weaknesses
  • Identification of goals and actions necessary to provide for needs
  • The types of services and service providers to whom the individual is referred
  • The frequency of those services

The case management support plan should include the following information, as appropriate:

  • How often will you see the case manager
  • Information about what is important to you
  • Your emergency response plan
  • Services to address any health and safety needs you have while residing in a residential setting 

A waiver case manager must review the case management support plan annually.

Referral and linkage

This step involves a case manager’s activities to “link” an individual with organizations capable of providing the needed services, also called “providers.” For example, a case manager may refer providers or schedule appointments.

Monitoring and follow-up

This case manager’s duty is to make sure the care plan is effectively carried out and meets an individual’s current and future needs. A waiver case manager must:

  • Meet with you face-to-face at least once every 90 days (3 months)
  • Visit your home once every 180 days (6 months)
  • Communicate with you by phone or email at least every 30 days, or more often if needed

Medical Necessity

Medicaid only approves treatments it decides are medically necessary. Medical necessity generally means that the service is needed to meet a specific medical need, such as an X-ray to diagnose a specific condition, medication to treat a specific condition or nursing services to provide wound treatment. For this reason, Medicaid may require a doctor’s order to specify why a service meets a person’s medical needs.

Non-Emergency Medical Transportation (NEMT)

Non-Emergency Medical Transportation (NEMT) ensures that people receiving Medicaid can access transportation to and from medical appointments. People can use NEMT to get rides for doctor’s visits, medical testing, picking up medications, routine medical procedures like dialysis, or other medical needs. A company called Modivcare provides this service to Medicaid members. People should call Modivcare to reserve a ride three business days before an appointment.

Modivcare

Website  https://www.modivcare.com/

Phone: 1-866-420-6231

Early and Periodic Screening, Diagnostic, and Treatment

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is an important benefit for people under 21. It offers regular tests, evaluations, and screenings to find and treat health problems early. These screenings include physical exams, dental checks, vision and hearing tests, psychological evaluations, behavior assessments, and more.

When a health problem is found, EPSDT requires Medicaid to provide almost any needed service to help fix or improve the condition. This means Medicaid must help find a healthcare provider and pay for the service. The service does not need to cure the condition; it must simply help correct, improve, or prevent it from worsening.

The State cannot limit medically necessary services under EPSDT. This means the State must provide all required services to children as allowed by federal law. This includes services the State does not currently provide to adults, like personal care services and private duty nursing. State Medicaid policy cannot limit a child’s right to EPSDT services under federal law. 

EPSDT covers services that help restore lost skills (rehabilitative services) but does not cover services that teach new skills (habilitative services). Generally, habilitative services are covered only by a Medicaid Home and Community-Based Services (HCBS) Waiver program. EPSDT also does not cover experimental treatment.

Health Insurance Premium Payment (HIPP) Program

The HIPP Program is a Medicaid program that helps families keep their private health insurance. If someone in your family is on Medicaid and also has private insurance, HIPP may help pay for the cost of that private insurance. The goal is to keep your private insurance active. Private insurance pays for care first. Medicaid helps with any costs that are left. To apply, fill out and send in the HIPP referral form.

Home Again Program

The Home Again Program (also referred to as Money Follows the Person) is a program to help Medicaid members transition from institutional settings into the community. Currently, Home Again provides services for people moving out of hospitals and nursing homes. To qualify, the person must reside in either a hospital or skilled nursing facility for sixty days before and require an intermediate or skilled level of care. Home Again can provide a transition coordinator to help the person find the right services and supports in the community. The Home Again program can help people enroll in the Community Choices waiver as part of their transition into the community.

‹ Previous - 1.4 Fee for Service Medicaid and Managed Care Organizations