Confused- Medicaid Vs. Managed Care Req?

[boogie_badd8nt_she 43]

Just got my date! July 27

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Holy cow! !!! Congratulations! !!! ARE YOU NERVOUS? !?! I have butterflies for you !!!!!!!!????????????????

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[silverthreads 183]

@boogie_badd8nt_she I can explain your original question. Medicaid is a program run by your state, jointly funded by the state and federal government. In your case, the state medicaid agency has contracted with Molina to handle your care -- so Molina's standards rule the day. Molina's standards can't be more difficult than the state's, but they can be more generous.

Companies like Molina make their money mostly by managing the care more carefully than the state ever could. So they have utilization management staff (usually nurses) that work with patients that have chronic conditions, etc. That doesn't mean they're rationing care -- sometimes they actually encourage people to get tests or go to the doctor more. It does mean that they won't let you get an MRI just because you have a funny headache today and think you need one -- it's just not appropriate unless you have a history of headaches and have been worked up for that.

[boogie_badd8nt_she 43]

@boogie_badd8nt_she I can explain your original question. Medicaid is a program run by your state, jointly funded by the state and federal government. In your case, the state medicaid agency has contracted with Molina to handle your care -- so Molina's standards rule the day. Molina's standards can't be more difficult than the state's, but they can be more generous.

Companies like Molina make their money mostly by managing the care more carefully than the state ever could. So they have utilization management staff (usually nurses) that work with patients that have chronic conditions, etc. That doesn't mean they're rationing care -- sometimes they actually encourage people to get tests or go to the doctor more. It does mean that they won't let you get an MRI just because you have a funny headache today and think you need one -- it's just not appropriate unless you have a history of headaches and have been worked up for that.

This is a solid explanation. thanks!!! U appreciate you both for your input.. I feel a lot better about pursuing this now! !!

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[Chicken Lady 102]

Yes- butterflies! And I feel like I forgot everything I'm supposed to be doing pre-op..,

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[boogie_badd8nt_she 43]

Yes- butterflies! And I feel like I forgot everything I'm supposed to be doing pre-op..,

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Hahahaha I can imagine... keep me updated blow by blow! !! Congrats again,K! ????????????????????????

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[Caribear 184]

Molina's standards rule the day. Molina's standards can't be more difficult than the state's, but they can be more generous.

I have to say that this is not always true for all managed care programs. I have Caresource in Ohio. Ohio Medicaid requires 6 months of doctor supervised diet, and comorbidities if your BMI is below 40. Caresource, however, requires 9 months of supervised diet, and will only approve you with no comorbidities if your BMI is over 50. BMI 45-50 requires one comorbidity, 35-45 requires two or more.

The bottom line is that your Managed Care Plan dictates what you are required to do, and that it is always a good idea to get those requirements in writing if at all possible.

[boogie_badd8nt_she 43]

Molina's standards rule the day. Molina's standards can't be more difficult than the state's, but they can be more generous.

I have to say that this is not always true for all managed care programs. I have Caresource in Ohio. Ohio Medicaid requires 6 months of doctor supervised diet, and comorbidities if your BMI is below 40. Caresource, however, requires 9 months of supervised diet, and will only approve you with no comorbidities if your BMI is over 50. BMI 45-50 requires one comorbidity, 35-45 requires two or more.

The bottom line is that your Managed Care Plan dictates what you are required to do, and that it is always a good idea to get those requirements in writing if at all possible.

Understood completely, thanks for input on this... I'm sure will help some people understand this more

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[Vjo 0]

What was arkansas requirements?

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[boogie_badd8nt_she 43]

What was arkansas requirements?

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Hi!!! Here you go!

A. The beneficiary must be between 18 and 65 years of age.

B. The beneficiary has a documented body-mass index >35 and has at least one co-

morbidity related to obesity.

C. The beneficiary must be free of endocrine disease as supported by an endocrine

study consisting of a T3, T4, blood sugar and a 17-Keto Steroid or Plasma Cortisol.

D. Under the supervision of a physician, the beneficiary has made at least one

documented attempt to lose weight in the past. The medically supervised weight

loss attempt(s) as defined above must have been at least six months in duration.

E. Medical and psychiatric contraindications to the surgical procedure have been

ruled out (and referrals made as necessary)

1. A complete history and physical, documenting the beneficiaries:

a. Height, Weight, and BMI;

b. The exclusion or diagnosis of genetic or syndromic obesity, such as

Prader-Willi Syndrome

2. A psychiatric evaluation no more than three months prior to requesting

authorization. The evaluation should address the following:

a. Ability to provide, without coercion, informed consent;

b. Family and social support;

c. Patient ability to comply with the postoperative care plan and identify

potential psychiatric contraindications.

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[lala2you 4]

This is crazy I have molina apple health. And I tried to get information on this year's ago and they said they don't cover baratric surgery period. My bmi is over 40 and I don't have any other health issues can one of you inbox me some contact information from molina? How do I find out who my case manage is?

[Chicken Lady 102]

@@lala2you - I sent you a message

HW - 283

SW- 238

CW- ?