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Frequently Asked Questions
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What is the
Maryland Healthy Kids Program?
The Maryland Healthy Kids
Program is the preventive, well-child, component of the Early and
Periodic Screening, Diagnosis and Treatment (EPSDT) Program for the
State of Maryland. The EPSDT Program is a federal requirement that
mandates that States cover certain benefits for Medicaid recipients
from birth through 20 years of age, benefits that are not necessarily
covered for recipients who are 21 years of age and older. The
Maryland Healthy Kids Program and the Maryland Department of Health
and Mental Hygiene offer services to EPSDT providers including
training and support services provided by our nurse consultants and
free vaccines through the Vaccines for Children Program.
Maryland Medicaid also operates
similar programs for moderate to low-income children, who are eligible
for Medicaid through the Maryland Children’s Health Program (MCHP) and
MCHP Premium Program. Medicaid, MCHP and MCHP Premium provide
children with the same comprehensive EPSDT benefit package and all
fall under the Healthy Kids Program.
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How do I apply for a Medical Assistance Provider Number?
Providers may obtain an
application packet to apply for a Medical Assistance provider number
by calling Provider Enrollment at 410-767-5340, or logging onto
www.emdhealthchoice.org
and selecting Services for Medical
Care Providers.
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Who needs to be “Certified” by the Maryland Healthy Kids Program?
All primary care providers
who plan to serve Maryland Medicaid/MCHP children under 21 years of
age must be certified by the Maryland Healthy Kids Program. The
certification requirement applies to PCPs contracted with MCOs and
PCPs providing care to recipients not enrolled with an MCO (commonly
referred to as “fee-for-service” and using a red and white Medical
Assistance card). Providers needing certification as primary care
providers include solo practitioners, group practices and rendering
providers within group practices who are:
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Board certified
providers in pediatrics, family medicine and internal medicine |
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Licensed physicians
and osteopaths, and certified nurse practitioners |
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Health care
providers such as federally qualified health centers, hospital
outpatient department clinics and school-based health
centers. |
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How do I become
Healthy Kids “Certified”?
Certification involves completion of the
Provider Application for Certification and Participation and a
face-to-face meeting with a Maryland Healthy Kids Program Nurse
Consultant to review the standards of preventive health care described
in the Maryland Healthy Kids Program Manual and the Maryland Schedule
of Preventive Care.
Contact the Maryland Healthy Kids
Program at 410-767-1683 to schedule a certification visit with the
Program consultant in your area or to check your current certification
status. A follow-up letter of certification is sent to you and your
contracted MCOs that should be saved as a reference for future MCO
credentialing.
Please note that Healthy Kids
certification is the same as EPSDT certification, as noted on
Maryland’s Uniform Credentialing Form. There is no distinct
certification number. Your certification is attached to your Maryland
medical assistance number, and this number can be used as your EPSDT
certification number.
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Will my Healthy Kids Certification end when I leave my current
practice?
Once you are certified and demonstrate
compliance with the Healthy Kids Program, the certification stays with
you, as long as you continue to provide services to
children/adolescents on MA, regardless of whether you change practice
sites or open your own private practice. Therefore, it is
important to notify the Healthy Kids Program nurse consultant in your
area of any changes to your practice.
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What is a
Managed Care Organization (MCO)?
Managed Care Organizations (MCOs) are
health care organizations that provide health care services to
Medicaid recipients in Maryland, under the direction of the
HealthChoice Program. MCOs are responsible for providing, or
arranging for, the full range of health care services. These
organizations contract with a network of providers to provide covered
health services to their enrollees. There are currently 7 MCOs
participating in HealthChoice.
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AMERIGROUP Maryland,
Inc. |
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Diamond Plan from
Coventry Health Care |
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Helix Family Choice |
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JAI Medical Systems |
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Maryland Physicians
Care |
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Priority Partners |
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UnitedHealthcare/AmeriChoice |
Additional Information on
HealthChoice and MCOs may be obtained by visiting the HealthChoice
website at
www.dhmh.state.md.us/mma/healthchoice/. Contact information for
the individual MCOs is available on this site.
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How can I provide healthcare to children and/or adolescents on
Medical Assistance?
PCPs establish individual contracts with
one or more of the seven MCOs. The contracted MCOs assign member
Medical Assistance recipients to that provider. Providers who wish to
enroll in one or more MCOs should contact each MCO’s Provider
Relations Department. The contacts for each MCO can be found in the
Maryland Healthy Kids Program Clinical and Administrative Manual at:
www.dhmh.state.md.us/epsdt/healthykids/
manual/table_contents.htm.
Locate Section 7 – Appendix V and click on Managed Care Organizations.
HealthChoice regulations require that MCOs
assign recipients younger than 21 years of age to a Healthy Kids
certified PCP. The regulations that govern the Medicaid HealthChoice
Program are 10.09.62-74 and can be viewed at
www.dsd.state.md.us/comar. Specific information about each of the
MCOs, including preauthorization phone numbers, customer service
lines, 24 hour Nurse Help Lines, as well as pharmacy, vision, and
dental services vendors, can also be found in Section 7- Appendix V of
the Maryland Healthy Kids Program manual (location information noted
above).
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Can I limit the number of children on Medical Assistance and the
ages of the children/adolescents that I serve?
Yes. You will need to indicate the number
of children and/or adolescents, as well as the minimum and maximum
ages, you want to serve for each of your contracted MCOs. Since
recipients with a Maryland Medical Assistance Fee-For-Service card
(the red and white card) are not assigned to specific providers, your
practice can determine whether to accept these recipients as they call
to make an appointment.
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How much will I be paid to provide preventive care to a child on
Medical Assistance?
Each MCO that you contract with will set
their reimbursement rates, but those rates must at least meet the
compensation rates set by Maryland Medicaid Fee for Service.
Information on the reimbursement for care provided to Maryland
Medicaid Fee-For-Service recipients can be found on the Maryland
Medicaid Provider Information page at
www.dhmh.state.md.us/mma/providerinfo by selecting the most recent
Physicians Services Provider Fee Manual. This page also contains
additional information for providers who serve, or are considering
service to Maryland’s children on Medical Assistance.
Vaccines are provided through the Vaccines
For Children (VFC) Program for patients up to 19 years of age. At
present, the State and MCOs reimburse the provider for administrative
costs associated with administering VFC supplied vaccines. Currently,
Medicaid pays an administration fee of $10 (maximum) per VFC vaccine.
For vaccines not included in the VFC
Program, such as Meningococcal Polysaccharide Vaccine (CPT Code 90733)
and other medically necessary vaccines, as well as for vaccines for
patients 19 – 20 years of age, Medicaid will reimburse the
acquisition cost of vaccines purchased by the provider and
administered to “fee for service” recipients. An administration fee
will not be paid for these vaccines. The “fee for service” CPT Codes
are listed in Section 6 – Billing and Encounter Data Reporting of the
Maryland Healthy Kids Program Clinical and Administrative Manual.
Check with each MCO for their vaccine reimbursement rates.
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What is
the Vaccines for Children (VFC) Program?
The Vaccines for Children Program is a
federal initiative begun in October 1, 1994 that provides vaccines to
health care providers, at no cost, for children/adolescents under 19
years of age who qualify in at least one of the following ways:
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Eligible for Medical
Assistance |
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Uninsured, without
health insurance |
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Under-insured,
covered by private insurance that does not pay for
immunizations, or |
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Native American
Indian or Alaskan Native |
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Why must I participate in
VFC?
The Maryland Healthy Kids Program requires
that providers enroll in the Maryland VFC Program, regardless of
whether the provider is participating with a MCO or fee-for-service
with the State. The cost of vaccines, available through the VFC
Program, will not be reimbursed either through “fee-for-service” or by
the MCOs. Only an administration fee, $10 maximum, will be
reimbursed for vaccines available through the VFC Program.
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What can the Healthy Kids Program Nurse Consultants do for my
practice and me?
Healthy Kids Program Nurse Consultant can:
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Orient and train
staff in Program standards and procedures; |
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Certify new
providers entering group practices or establishing new solo
practices; |
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Distribute
applicable Clinical and Program manuals/materials; |
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Explain Medicaid
health policies and federal/state regulations; |
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Assist in the
improvement of the practice’s performance through medical record
reviews; |
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Assistance with
Medicaid billing and MCO encounter data reporting issues; and |
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Educate providers
about MCO and Local Health Department referral process for
outreach and health related services. |
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How can I access the Healthy Kids Program Clinical and
Administrative Manual?
The Healthy Kids
Program Clinical and Administrative Manual can be viewed at:
www.dhmh.state.md.us/epsdt/healthykids/ and click on Provider
Manual. Many selections in the manual can be downloaded in the PDF
format.
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Martin
O'Malley, Governor
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