Medical Services

Managed Care

State Plan Amendment - Title XIX of the Social Security Act

Supplement 7 - Exempt Services

Emergency Services

Emergency services are outside of the managed care program. The State must cover and pay for emergency services regardless of whether the provider that furnishes the services has a PCCM contract with the State. The State may not deny payment for treatment obtained when an enrollee had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified under “emergency medical condition” listed below. The State may not deny payment for treatment obtained when a representative of the PCP instructs the enrollee to seek emergency services. When a Medical Assistance managed care beneficiary requires emergency care a referral/authorization is not required.

Emergency Services Defined

An “emergency medical condition”: is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
  • Serious impairment to bodily functions; or
  • Serious dysfunction of any bodily organ or part.

All services needed to evaluate or stabilize an emergency medical condition are considered emergency services and therefore exempt from PCP referral requirements.

Exempt Mental Health Services

Medical Assistance eligible recipients diagnosed as SED (Severely Emotionally Disturbed) or SPMI (Severely and Persistently Mentally Ill) by their mental health professional are excluded from Managed Care requirements for Mental Health Services Only. Authorization from the PCP for all other managed care services is required.

Other exempt services

Services listed below are exempt from PCP referral requirements:

  • Anesthesiology
  • Chiropractic Services
  • Dental
  • Family Planning Services
  • Hospice
  • Immunizations
  • Independent Lab and X-Ray
  • Nursing Facility
  • Pharmacy
  • Respiratory Care
  • School-Based Primary Health Care Services (only specifically-listed services)
  • Substance Abuse Treatment Services i.e. for children and pregnant women
  • Testing for Sexually Transmitted Diseases (STD’s)
  • Transportation – Emergency
  • Transportation – Non-Emergency
  • Vision Exams and Glasses