| Overview
Prepaid health care plans serve a diverse population, including Medi-Cal, Medicare, and employer or individually paid plans.
Medi-Cal and Medicare Prepaid Health Care Plans are capitated programs in which the consumer has opted or been placed in a specific prepaid health care plan in lieu of the fee-for-service, choice of provider plan. The plan or carrier has already been paid by the government to provide both health and mental health services.
A Private Prepaid Health Care Plan is an insurance plan obtained through an employer, organization, or personally by the consumer. The prepaid health care plan is paid a financial consideration by the employer, organization, or the consumer to provide health care, including mental health benefits. Many prepaid health care plans operate as both private and Medi-Cal and/or Medicare providers.
There are currently many indemnity insurance companies which offer Primary Care Physician Plans (PCPP). These are private insurance plans often offered at a reduced cost to the consumer, however, requiring prior authorization by the PCPP for care outside of the plan.
Effective September 1, 1993, Managed Care Plans (MCPs) replaced Primary Care Case Management Programs (PCCMs). Persons applying for Aid to Families with Dependent Children (AFDC) who have not already selected a primary care physician will be assigned a primary care physician under a prepaid health care plan. Persons already assigned to a PCCM will be allowed to continue with that program.
Medicare Prepaid Health Care Plans
Medicare prepaid health care plans are capitated plans which have been paid to provide health services and mental health services. These plans allow for treatment of covered services outside the plan, only for medically necessary treatment, with prior authorization from the prepaid health care plan, or when the client chooses to personally pay for the cost of treatment.
When a Medicare prepaid health care plan denies authorization, and the consumer chooses to use the services of the Department or their contract providers, the consumer is responsible for the full cost of care.
Collection Follow Up
The Medicare Prepaid Health Care Plan is responsible for payment of the full cost of care for authorized services, and is to be billed. If routine collection efforts fail to result in payment, directly operated or County-contracted provider staff are to employ stronger methods including, but not limited to, referral to the Treasurer Tax Collector.
Medicare beneficiaries are responsible for payment for services solicited by them and must pay immediately following each visit. No further treatment is to be provided until each prior visit is paid for.
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| Clients receiving Medicare benefits through MCPs, e.g., Health Maintenance Organizations (HMO), Prepaid Health Plans (PHP), PCPP, and PCCM, must first look to those entities as being responsible for the provision of their mental health services as defined by their contracted benefits. -
If Medicare beneficiaries present themselves at a DMH directly operated clinic or contract agency, the beneficiaries should be advised that their health care plan is responsible for managing their care. Except in cases deemed medically necessary, the beneficiaries should be referred back to their respective plan unless the prepaid health care plan or the Medicare beneficiaries, as appropriate, are willing to pay for the full cost of their care.
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Medically necessary services describes an emergent situation requiring immediate treatment. A service is medically necessary when it is reasonable and necessary to prevent significant illness, or to alleviate severe pain. (WIC 14059.5) |
