Sometimes It can be hard to access the care you or your children need in a managed care system. Maybe you have a concern about a provider's office hours or  the office's accessibility.  Or you may have been denied care that you and/or doctors think is medically necessary.

The HealthChoice program offers protections and help for just these kinds of problems.  Enrollees have a right to appeal to their health plan and the state when care has been denied, stopped, or when there has been a reduction in care.  Enrollees also have the right to voice complaints about services they received.  They can call the customer service number listed on their health plan card and the state at anytime.

What Rights Does an Enrollee Have in HealthChoice (Medicaid or MCHP)?

When a HealthChoice enrollee has been denied services, care, or supplies/equipment by a managed care organization (MCO) or when an MCO has reduced or terminated a current service, State and Federal protections are in place to help.

• HealthChoice enrollees must be informed in writing by the MCO, in a timely way, when a benefit is denied or before a benefit is reduced or terminated (ten days before a reduction or termination in service)

• Enrollees and providers must be told why the service is being denied, reduced, or terminated and be informed of their appeal rights and the circumstances under which the benefit will continue.

• When an appeal has been filed, an MCO may not discontinue, terminate, refuse to authorize, or refuse to pay for any benefit or service unless the state agrees with the MCO.

• Staff at the HealthChoice Enrollee Action Line have ten days to try to resolve an issue (unless it is an emergency)

• Enrollees have 30 days to file for a fair hearing.  Parents, providers, and advocates should be aware that the deadline for filing for a fair hearing is 90 days for the Public Mental Health System.

Do You Need Help Understanding the Complaint Process?

When you have a complaint or want to appeal a denial of health care services, wading through the process can seem overwhelming.  Our Consumer Ombudsman and Assistance Program (COAP) can help you to understand the State and MCO system. 

We may be reached at 410-640-0510 or by e-mail to answer your questions and help you get the health care services you need.  We are also available to help providers navigate the MCO and State systems by providing free on-site in-services to medical and office staff.

You may also download our HealthChoice Primer.  The Primer includes information on HealthChoice access, summary information of pertinent regulations, and complete complaint and appeal information.

Click here to download your copy. 

Your comments, questions, and concerns are welcome. 

Click here for our Grievance Policy.

Therese McIntyre

Website Development

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2004 Baltimore HealthCare Access (BHCA)  Updated 11/21/07