The Maryland Medicaid Program Covers:
Medicaid (also called Medical Assistance) is a program that pays the medical bills of people who have low income and cannot afford medical care. Medicaid provides three types of critical health protection:
Health insurance for low-income families, children, the elderly, and people with disabilities;
Long-term care for older Americans and individuals
Supplemental coverage for low-income Medicare beneficiaries (e.g., payment of Medicare premiums, deductibles, and cost sharing).
Medicaid is a joint federal and state program. Each state establishes its own eligibility standards, benefits package, provider requirements, payment rates, and program administration under broad federal guidelines. The Department of Health and Mental Hygiene (DHMH) runs Maryland’s Medicaid program.
How do Medicaid Eligibles Receive Services?
Once someone has filed an application and been determined eligible for Medicaid, they will likely receive their medical services through the State’s Medicaid Managed Care Program, HealthChoice. If someone qualifies for HealthChoice, they will choose a Primary Care Provider (PCP) and be enrolled with a Managed Care Organization (MCO) of their choice.
If the person does not qualify for HealthChoice (e.g., because they are also Medicare eligible, eligible for Medicaid through spenddown, or eligible in a long-term care facility), they will still receive Medicaid services, but through “fee-for-service” (FFS). This means that each medical provider who provides services to the Medicaid recipient bills the Medicaid program for payment. Prior to HealthChoice and other managed care programs, all provider claims for Medicaid services were handled this way.
Under HealthChoice managed care, the MCOs contract with DHMH to provide Medicaid covered services through their provider networks in return for monthly payments from DHMH. This set of services is called the “Benefits Package”. The MCOs pay the providers in their networks for these services. Some Medicaid services are not covered by the MCOs, and may be received through Medicaid fee-for-service (such as therapies for children). Specialty mental health services are provided by the State’s public mental health system. All Medicaid eligibles with full coverage receive the same services, whether or not enrolled in an MCO. About 20% of Medicaid eligibles are NOT enrolled in managed care, so their providers are paid fee-for-service by DHMH