Introduction to Managed Care
 

Most people who receive Medicaid get their health care through a managed health care system.  HMOs are only one type of managed care program, but in Milwaukee, HMOs are the most common type of managed care program.  As a Medicaid recipient, you have the right to choose an HMO based on your needs.

What is managed care?
Managed care is a program where you receive all of your medical services from one health plan. If you are on Medicaid you may be required to choose an HMO. If you do not choose one, the state will choose one for you. Managed care focuses on preventive care. Preventive care means that your doctor takes care of your health care needs before you get sick. In the past, you may only have seen a doctor when you were sick.

Who needs to enroll in HMOs?
Most Medicaid recipients in Wisconsin are now enrolled in HMOs. You will get a letter in the mail telling you if you must enroll in an HMO.

Call the Medicaid Enrollment Specialist at 800-291-2002 if you have questions about the HMO program.

Are there rules to follow in my HMO?
You should receive a handbook from your HMO explaining the rules. The box below lists some of the rules that all HMOs share.
 

You and your family must get most of your health care from your HMO plan. Family planning and AODA/mental health services are some exceptions.   You must choose one doctor for each member of your family who will care for you. That doctor is called the primary care provider or PCP.   Your primary care provider will refer you to a specialist only if he or she decides you need one.   You must bring your Medicaid card with you to all your appointments.   You must make arrangements with your HMO if you plan on traveling more than 50 miles outside of Milwaukee and if you need routine care from a doctor while you’re away.   You should only use the hospital emergency room if you have a very serious illness or injury that needs immediate treatment. See EMERGENCY CARE

If you disagree with any action taken by your HMO and it prevents you from getting the care you need, you can file a grievance or request a fair hearing.  See FILING A GRIEVANCE or  REQUESTING A FAIR HEARING

Remember, if you need help you can call the HMO Ombuds Program, at 800-760-0001 or the Health Advocacy Project at 414-278-7722 (Legal Action) or 414-449-4777 (Community Advocates).

What is the difference between regular Medicaid and a Medicaid-HMO?
A Medicaid recipient who is enrolled in an HMO must receive all his or her medical care from the doctors in the HMO. In contrast, a Medicaid recipient who has regular Medicaid (fee-for-service) can go to any doctor who accepts Medicaid.

Are there different types of HMOs?
Yes, there are two. A network-based HMO has doctors in many different locations. A clinic-based HMO has all its doctors, specialists, lab, pharmacy, etc. in one building. The advantage of choosing a clinic-based HMO is that you can get most of the care you need in one place. The disadvantage is that your choice of doctors and specialists may be restricted to the providers in the clinic.

What are the benefits of joining an HMO?
HMOs focus on preventive care rather than only treating you when you are sick. You can choose a primary care doctor who will coordinate all your care. If you are in a Medicaid-HMO you will receive all services covered by the Wisconsin Medicaid program. You may also receive some health services not covered by Medicaid. If you are enrolled in a Medicaid-HMO, you will not be required to pay anything for services covered by the Medicaid program, except for small co-payments for some services.