Choosing a Provider 

Who is a Medicaid provider? 
A Medicaid provider is a doctor, nurse practitioner, hospital or clinic that has agreed with the state to see Medicaid patients. If you are in an HMO, you will have to choose a doctor from the HMO who will take care of all your health care needs. This doctor is called your primary care provider. 

How do I choose my primary care provider? 
If your current doctor is in one of the Medicaid-HMOs, you can choose that doctor as your primary care provider. Otherwise, your HMO will send you a list of doctors that you can choose from. Once you choose your primary care provider you can change at least twice a year or any time if you have good cause. Call your HMO customer service representative and request a change. 

Do my children and I need to have the same primary care provider? 
No. Every family member can have a different primary care provider. All family members living in the same household must be in the same HMO. If a family member is disabled and is receiving SSI, she will not be in an HMO at this time. You could request an exemption from the HMO for the rest of the family, if you have difficulty getting care. 

What if I don’t want to change the doctor that I now have? 
You should talk to your doctor to see if he or she belongs to a Medicaid - HMO. If not, you may have to change your doctor. 

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 happens if I need to see a specialist? 
Your primary care provider is also the person who approves visits to hospitals and specialty doctors. Your primary care provider is required to make sure that you do not get unnecessary referrals and services. However, it is important to keep in close contact with your doctor to make sure that you do get the health care that you and your family need. 

If you see a specialist more than your primary care provider, you may want to request that your specialist be assigned as your primary care provider. Call the Enrollment Specialist at 800-291-2002 for help. 

What is an out-of-plan referral? 
An out-of-plan referral is a referral to a hospital or specialist outside of the HMO network when the HMO does not offer the services that you need. 
 

Example: If you need specialized cancer surgery that your HMO cannot provide, you can request a referral to a surgeon outside of your plan. If the HMO denies you an out-of-plan referral, you can file a grievance or request a hearing. See FILING A GRIEVANCE  or REQUESTING A FAIR HEARING

 
What if I don’t agree with my doctor’s opinion? 
If you do not agree with your doctor’s medical opinion, you have a right to get a second opinion. Talk with your doctor or contact your HMO for more information about requesting a second opinion.