DHS uses the following payment methods to pay for MA services:
Fee for service
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Under the fee-for-service system, eligible individuals receive an ACCESS card. Medical providers use the cards to identify eligible individuals, access the Eligibility Verification System (EVS), bill the DHS, and find out what health care benefits each individual can receive. The DHS directly pays providers who are enrolled in the program. Payment is based on a fee for service, and the fees are set in advance by the DHS. Recipients have to make small copayments for certain services or items. There is no copayment for services provided to children.
Diagnosis-related grouping (DRG).
Hospitals are paid using a Prospective Payment System (PPS). Under PPS, hospitals are paid pre-determined rates based on diagnosis-related grouping (DRG). The DRG payment is set by the diagnosis, the procedures performed, and the patient’s age, sex, and health status.
Managed care or prepaid capitation programs.
Eligible individuals receive managed medical care and services through a provider for a fixed amount each month. (This amount is called the monthly premium.) Each patient chooses a primary care physician, who is responsible for managing or providing all that patient’s health care services. This includes referring the patient to specialists when necessary and handling inpatient admissions.
There are currently three types of managed care programs: health maintenance organizations (HMOs), health insurance organization (HIOs), and capitation contracts with community health centers. Managed care plans offer the same benefits that are covered in the fee-for-service system, such as hospitalization, inpatient physician care, outpatient surgery, eye and hearing examinations, podiatry, maternity services, and mental health services. Managed care plans let patients receive ongoing care by the same providers and have access to practitioners and specialists. Each patient in a managed care plan receives an ID card. The patient also receives an ACCESS card which covers services not covered by the plan.
Primary Care Case-Management (PCCM) system
Individuals enrolled in PCCM are linked with primary care providers who give or manage access to services. Because patients receive primary and preventive care on a regular basis, they are less likely to use hospital emergency rooms for regular medical care. An example of PCCM is Access Plus. (For information on the Access Plus, see Section 309.521.)
Updated February 14, 2012, Replacing February 8, 2002