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:
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.
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.
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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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 8 MCOs participating in HealthChoice:
• AMERIGROUP Community Care;
• Jai Medical Systems, Inc.;
• Kaiser Permanente;
• Maryland Physicians Care;
• Medstar Family Choice, Inc.;
• Priority Partners;
• Riverside Healthcare;
• United Healthcare.
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PCPs establish individual contracts with one or more of the eight 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 Provider Manual (Refer to Section 8, Telephone Directories, Maryland Medicaid HealthChoice MCOs Resource List).
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
http://www.dsd.state.md.us/COMAR/ComarHome.html. 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 8, Telephone Directories of the Maryland Healthy Kids Program Manual.
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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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.maryland.gov/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.
For vaccines not included in the VFC Program and other medically necessary 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 rate.
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:
• Eligible for Medical Assistance;
• Uninsured, without health insurance;
• Underinsured, covered by private insurance that does not pay for immunizations;
• Native American Indian or Alaskan Native.
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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.
The Healthy Kids Program Nurse Consultant can:
• Orient and train staff in Program standards and procedures;
• Certify new providers entering group practices or establishing solo practices;
• Distribute applicable Program manuals/materials;
• Explain Medicaid policies and federal/state regulations;
• Assist in the improvement of the practice’s performance through medical record reviews;
• Provide assistance with Medicaid billing and MCO encounter data reporting issues;
• Educate providers about MCO and Local Health Department referral process for outreach and health related services.
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The Healthy Kids Program Clinical and Administrative Manual can be viewed at:
https://health.maryland.gov/mmcp/epsdt and click on Provider Manual. Many selections in the manual can be downloaded in the PDF format.
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