MEDICAID HMOs 

What is an HMO? If I have Medicaid will I 
need to join an HMO? 
The state has contracted with private companies called Health Maintenance Organizations (HMO) to manage your health care. 

If you have dependent children and you are on Medicaid, Healthy Start, or BadgerCare you may need to join an HMO.

If you are in an HMO you will have to get all your medical care, including mental health, alcohol and drug treatment, from the doctors and hospitals who are in your HMO. 

You will have to choose a primary care doctor who will take care of your health needs. If you need to see a specialist, you must ask your primary doctor for a referral.

You do not need a referral from your primary care doctor to get alcohol, drug treatment or mental health services. Each HMO has a mental health “gatekeeper” who you need to call for mental health, alcohol or drug treatment. See  HMOs IN MILWAUKEE 

If you have special health care needs that your HMO cannot take care of you can ask for an exemption from the HMO. If you get an exemption, you can go to any doctor who accepts Medicaid. 

How do I sign up for an HMO? 
Once you have Medicaid, you will get papers to sign up for an HMO. You have about six weeks to sign up. If you or your children have doctors or you are receiving treatment from a specialist or a hospital, you should find out whether they are part of an HMO. If they are, you can choose that HMO. 

If you do not sign up within six weeks, the state will pick an HMO for you. If this happens, you have 90 days to change to another HMO. If you do not change during this time, you will be “locked” into that HMO for nine months. After this time, you can change only if you can show that you have a serious reason for not being in that HMO. 

The HMO Enrollment Specialist can help you choose or change your HMO, choose a doctor or clinic, request an exemption or give you other information about your HMO. Call 800-291-2002. 

What if I have problems with my HMO? 

If you have a problem with your doctor, your HMO, or the treatment you are getting or not getting, there are several ways you can get help:

Talk to your clinic staff, doctor, nurse or the customer service department of your HMO.

If you have an urgent problem or feel you are getting the run-around, ask to speak to the HMO Advocate who has been appointed by the HMO to help you.  See  HMOs IN MILWAUKEE .

Call the Managed Care Ombuds Program at 800-760-0001 for help.

If your HMO refuses to cover a medical service you need, or stops or reduces your services you can file a “grievance” with your HMO. A grievance is a written complaint to your HMO.

The HMO must respond to your complaint within 10 days. In an urgent case the HMO must get back to you within four days or sooner. 

Remember that you can always request a fair hearing without going through the HMO grievance steps.

If you request a fair hearing within 10 days of receiving a notice that your HMO will stop or reduce your medical care, the state must continue your services until a fair hearing decision is made.  See  FAIR HEARINGS .

The Health Advocacy Project can help you if you are having trouble with your Medicaid HMO. Call 414-278-7722 (Legal Action) or 414-449-4777 (Community Advocates) for more information.