801        GENERAL MEDICAID INFORMATION

801 A.        FREEDOM OF CHOICE OF PROVIDERS

Medicaid recipients are free to choose their own health care provider(s), as long as that provider is enrolled with the Alaska Medicaid program, with the following exceptions:

1)  When a recipient is placed in the Care Management Program; or

2)  When a recipient must use a non-enrolled provider during an emergency but that provider subsequently enrolls in the Medicaid program.

801 B.         FREEDOM OF CHOICE RESTRICTION - CARE MANAGEMENT PROGRAM

The state’s fiscal agent, Health Management Systems (HMS), administers the Care Management Program (CMP). HMSHealth Management Systems may restrict a recipient's choice of providers if they find that the recipient has used a medical service at a frequency or in an amount that is considered improper, excessive, or unusual. This restriction is imposed by placing a recipient into the CMPCare Management Program.

When this occurs, HMSHealth Management Systems will notify the recipient of the finding and assign the individual a provider who will be the only provider available they can use for the services identified by HMSHealth Management Systems. Once placed in the CMPCare Management Program, the recipient may not receive medical services from another enrolled provider without first getting a written referral from their care management provider, except in the case of a life threatening or potentially disabling emergency.

The recipient has a right to a fair hearing to contest this finding. Recipients may request a fair hearing by contacting either DPADivision of Public Assistance or the Medicaid Recipient Helpline, toll free at 1-800-780-9972 (both inside and outside of Anchorage area). A Fair Hearing Representative from the DHCSDivision of Health Care Services will then contact the recipient regarding this request.

When an individual is placed into the CMPCare Management Program, HMSHealth Management Systems staff will enter coding in the eligibility system. The Recipient Identification card for the individual will be mailed separately by HMSHealth Management Systems, usually within three days of the system issuance.

DPADivision of Public Assistance is unable to issue or print coupons for a CMPCare Management Program recipient but may contact HMSHealth Management Systems at 907-644-6842 to request coupons on behalf of the recipient

801 C.        "ONE DAY-ONE MONTH" PRINCIPLE

If a person is determined eligible for MAGIModified Adjusted Gross Income Medicaid for any day during a month, the person is eligible for Medicaid for the entire month.

Exception:

HPEHospital Presumptive Eligibility coverage does not have the "one day - one month" principle. See section 833.

801 D.       ELIGIBILITY IN ONE HOUSEHOLD

An individual may only be determined eligible as a member of one household at a time in any given month.

Exception:

An individual that has received HPEHospital Presumptive Eligibility coverage in a household may be determined eligible as a member of a different household for regular Medicaid in the same month of the HPEHospital Presumptive Eligibility coverage. See section 833.

801 E.        MEDICAID COVERED SERVICES

Payment for Medicaid services will only be made to enrolled providers. It is the responsibility of the recipient to find out if the medical provider is enrolled with Alaska Medicaid before receiving the service.

DHCSDivision of Health Care Services publishes and distributes the Alaska Medicaid Recipient Services booklet for all Medicaid recipients. This booklet gives detailed information about what medical services are covered by the Alaska Medicaid program and how to use those services. Many services require a prior-authorization by the medical provider before payment can be made by the Medicaid program.

Any services received by a recipient that are not covered by Medicaid, or were not prior authorized when required, are the responsibility of the recipient.

801 F.        MEDICAL SERVICES RECEIVED OUT OF STATE

Medical services may be received out of state if those services are not available in Alaska as long as the service is prior authorized and the health care provider is enrolled in the Alaska Medicaid program. Services received without prior authorization because of an emergency or because the recipient’s health would be endangered if required to return to Alaska to receive medical care may also be covered if the provider subsequently enrolls in the Medicaid program.

A recipient living in a community with convenient road access to a Canadian medical provider and no access to a U.S. medical provider, other than by chartered airplane, may receive medical care in the Canadian community.

Medicaid will reimburse covered services provided by Canadian providers if one of the following conditions is met:

1)  The services were provided because of a medical emergency. A medical emergency exists when a recipient has a severe, life threatening, or potential disabling condition that requires intervention within minutes or hours; or

2)  The State of Alaska has agreed that the needed health care services are more readily available in Canada at equal or less cost.

All other services received out-of-state must be prior authorized by HMSHealth Management Systems to be covered by Medicaid.