When an individual qualifies for Medical Assistance (MA) benefits, they are placed in one of two options to pay for their medical services.
Health Choices managed care plans (mandatory).
Fee-for-service (FFS).
Providers may use the Eligibility Verification System (EVS) to verify if an individual qualifies for MA. The EVS response will tell the provider the name and phone number of the plan in which the individual is placed.
Health Choices Managed Care Organizations (MCOs) are paid a monthly capitation fee to manage an individual’s medical services and needs. The goals of the MCOs are to make sure of the following:
Medical Assistance (MA) recipients have access to quality medical care.
They use medical services in a cost-effective way.
These goals are to be met by having individuals enroll in a plan and select or be assigned to specific medical providers. These Primary Care Providers (PCPs) are the individual’s primary source of medical care and control access to medical services that the individual may need from other medical providers. The PCPs must help the individual get medical services from other providers when they need it and must refer the individual to other community-based services when it is right to do so.
Fee-For-Service (FFS) allows an individual that cannot be enrolled into a managed care plan to receive payment for medical services on a per-service basis. The following MA recipients will be FFS:
An individual covered by Medicare.
An individual living in a long term care facility or an ICF/MR.
An individual eligible for MA for a period of less than three months.
An individual eligible only for a retroactive period.
An individual getting MA in the TR (extended medical benefits for SPOC) category.
An individual eligible for state or federal foster care or a subsidized adoption program (program status codes 31 through 35).
An individual getting MA in a State Blind Pension category (B or TB).
An individual over the age limit for the plan in effect in their county of residence.
Updated March 11,2013, Replacing February 14, 2012,