Maryland

In Maryland:
  • As of July 1, 2011, there were 986,304 beneficiaries enrolled in Maryland’s Medicaid program. Of these, 735,859 were enrolled in managed care. Most Medicaid enrollees, including children, are eligible to receive physical health services through the state’s mandatory managed care program, HealthChoice. Groups ineligible for managed care include enrollees in the state’s Model Waiver.
  • An administrative services organization (ASO), ValueOptions, administers a Public Mental Health System in Maryland. A separate ASO, DentaQuest, is responsible for administering the Medicaid oral health benefit for children, pregnant women, and certain adults in Maryland.
  • Home and Community-Based Services are aimed at children in Maryland through 1915(c) waivers:
    • Autism Waiver, which provides a range of services therapeutic and support services to children ages 1-21 who have an Individualized Family Service Plan or Individualized Education Program and meet the Intermediate Care Facility for Persons with Mental Retardation Level of Care;
    • Model Waiver for individuals under the age of 22 who, without care in the home, would be at risk of hospital admissions or institutional care
As of 2012, 643,569 individuals were eligible for Maryland’s Health Kids Program (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to CMS data from 2012, Maryland achieved an EPSDT screening ratio of 94% and a participation ratio of 64%. 332,479 children received dental services of any kind, with 305,394 receiving preventive dental services.

Last updated February 2014.

 
Medical Necessity
Under the Code of Maryland Regulations, "Medically necessary" means that the service or benefit is:
 
  1. Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
  2. Consistent with current accepted standards of good medical practice;
  3. The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and
  4. Not primarily for the convenience of the consumer, the consumer’s family, or the provider.
Initiatives to Improve Access
Maryland’s Medical Assistance Program funds local health departments to provide assistance to families when children under 21 need to access follow-up treatment services resulting from a Healthy Kids preventive care screen. Local health departments are also responsible for assisting high-risk beneficiaries, including children, to access necessary health care services. 
Reporting & Data Collection The state issues report cards on Medicaid managed care organizations (MCOs) that compare MCOs on several metrics, including “Keeping Kids Healthy.” This domain includes measures of:

  • Immunizations
  • Well-child visits to physicians and dentists
  • Lead testing
Behavioral Health
Service delivery
Primary mental health services in Maryland are mental health services provided in the primary care office; the state allows primary care providers to treat mental health conditions if the treatment falls within the scope of the provider’s practice, training and expertise. Conditions that cannot be treated in primary care settings are referred to the state’s local public mental health system.
 
The Specialty Mental Health System, frequently called the Public Mental Health System, provides a full range of mental health services. The Maryland Mental Hygiene Administration (MHA), along with local Core Service Agencies (CSAs), has oversight of the mental health authorities in each jurisdiction. Specialty mental health services are covered by Maryland Medicaid and available to all Medicaid recipients. 
 
Screening
Maryland requires that general developmental screening be performed for all children at the 9-, 18-, and 24-30 month Healthy Kids preventive care visits, and whenever a concern is identified through developmental surveillance. If the child is not seen at these recommended ages, screening should be conducted at the next preventive care visit. Healthy Kids recommends the following standardized, validated developmental screening tools for use in general developmental screening at the intervals noted above:
  • The Ages and Stages Questionnaire (ASQ)
  • Pediatric Evaluation of Developmental Status (PEDS), www.pedstest.com
 
The state also provides an additional list of approved standardized, validated general developmental screening tools.
 
In addition to requiring general developmental screening, the MD Healthy Kids Program recommends autism-specific surveillance at all visits and requires structured autism-specific screening at 18 and 24-30 month well child visits. The Maryland Healthy Kids Program recommends the Modified Checklist for Autism in Toddlers (MCHAT) screening instrument.
 
The Healthy Kids Program developed a series of age-specific Mental Health Questionnaires to help primary care providers identify behavioral and emotional problems. The state also allows providers to bill for substance abuse screening (using the 99408 and 99409 CPT codes) and recommends use of the CRAFFT substance abuse screening tool for adolescents.
Support to Providers and Families
Support to Families
Maryland’s Health Kids Program provides funds to the local health departments to collaborate with the MCOs and provide support services such as outreach, appointment scheduling, transportation assistance, tracking and case management services to assist with treatment for identified problems and assure continuity of care.
 
Support to Providers
Healthy Kids Program Nurse Consultants work to certify primary care providers to participate in the program, train staff on program standards and procedures, assist providers with program billing and reporting, and educate providers about referral processes.
 
The Department of Health and Mental Hygiene maintains an EPSDT website that contains resources for providers, including the provider manual, provider forms, and the state’s periodicity schedule.
Care Coordination
The state has produced the Maryland Uniform Consultation Referral Form to facilitate referrals and follow-up services when screens uncover health conditions in a child.
 
Maryland has an Administrative Care Coordination/Ombudsman (ACCU) program that provides information and consultation for Medicaid and managed care recipients to enhance their access to Medicaid services. Local health departments
provide linkages to care and care coordination services to “at risk” pregnant or postpartum women, and children to assist recipients with access and utilization of the managed care system and other health related services.
 
Maryland also has a multi-payer medical home program in which Medicaid participates.
Oral Health
Since 2009, all dental-related customer services for Maryland Medicaid beneficiaries have been coordinated by DentaQuest. DentaQuest is contracted to assist Medicaid enrollees in the “Maryland Healthy Smiles” Program locate dental care within a reasonable distance from the enrollees’ residence to ensure adequate access to oral health care services. Additionally, DentaQuest provides verification of dental benefits and eligibility verification.
 
The Maryland Healthy Smiles Dental Program is available for all Maryland Medicaid enrollees under 21 years of age as well as pregnant women. The program covers a variety of dental benefits for children, including fluoride treatment, cleanings, and fillings.
 
Through the Maryland’s Mouths Matter Fluoride Varnish and Oral Health Screening Program for Kids program, Maryland Medicaid reimburses for the application of fluoride varnish to Medicaid-enrolled children ages 9 months – 36 months old in primary care provider offices. Reimbursement by Medicaid is limited to EPSDT certified primary care providers who have successfully completed a state approved oral health screening and fluoride varnish program training program.