Medicaid HMO non covered service list

MCO Excluded Services

(Fee-For-Service)
The MCO’s are responsible for providing all Medicaid covered services excluding the following, which are paid fee-for-service by Medicaid:

Abortion Services – MCO’s are responsible for related services performed as part of a medical evaluation prior to the actual abortion.

 Aids Drug Therapies - Limited to Protease Inhibitors, Non-nucleoside Reverse Transcriptase Inhibitors and viral load testing.

Healthy Start Case Management Services

IEP/IFSP - Individual Education Plan (IEP) or Individual Family Services Plan (IFSP). Medically necessary services that are documented on the IEP or IFSP when delivered in schools or by Children’s Medical Services community based providers.

Medical Day Care Services

Nursing Home/Long Term Care Facility Services - After the first 30 consecutive days of care.

Personal Care Services

Rare & Expensive Case Management Services (REM) - Recipients are eligible based on one of the diagnoses listed in COMAR 10.09.69. Recipients receive all State Plan Medicaid services on a fee-for-service basis.

Specialty Mental Health Services - Including inpatient admissions to Institutions for Mental Disease (IMD). These services are payable through the Value Options Maryland. For information, call 1-800-888-1965.

Stop Loss Case Management (SLM) - A recipient participating in a MCO which does not self insure becomes eligible for the Stop Loss Case Management Program when his or her paid inpatient hospital services exceed $35,000.00. At that point, the Program pays 90% of inpatient charges, while the MCO pays the remainder. Once SLM eligibility is in effect, the recipient is also eligible to receive case management and additional services available through the REM Program.

 Transportation Services – MCO’s may, be responsible for transportation services that are not covered by fee-for-service Medicaid.

No comments:

Medical Billing Popular Articles