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Medicaid: How To Maximize Use

If Necessary, Learn How To Survive In A Medicaid HMO

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You will, however, have to function under two sets of rules: the rules of Medicaid and those that govern an HMO

The rules of Medicaid. You will have to follow all the normal rules of Medicaid, including maintaining your eligibility.

The rules that generally govern an HMO. A managed care plan under Medicaid is no different that other managed care plans such as HMOs. To learn more about life under managed care plans, see: HMO.

Also, look in the explanatory literature at:

  • The rules requiring a referral to a specialist.
  • Which providers you can see.
  • The requirements for covering emergency care out of the network. You will want to know this information in advance so you'll know what needs to be done to assure coverage.
  • Out-of-Service Area Care. Medicaid does not cover treatment in other states except for emergency situations of a life-threatening nature. This can be an even larger issue with HMOs since many only cover a limited service area instead of an entire state. Find out what happens if you live at one end of the state and you need important (though not emergency) treatment when you are visiting at the other end of the state where your HMO does not have facilities.

If you have a fee-for-service (indemnity) type of Medicaid policy and are told you must switch to a Medicaid HMO: In those districts where there is a gradual conversion of recipients from fee-for-service to HMO, most make concessions for people already under treatment for a serious illness. The most common concession is to permit people to remain in the fee-for-service plan or, if the fee-for-service plan is being terminated completely, to arrange for continuing treatment by your current doctor and other medical providers, at least temporarily.

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