Medicaid Operations

Medicaid Services

The Bureau of Medicaid Services is responsible for the development, coordination and implementation of Medicaid program policies and procedures and administration of the program's medical authorization functions. It plans, develops and implements Medicaid program policies, procedures and special projects. It is responsible for the development and maintenance of the Medicaid State Plan, administrative rules, and manuals related to services covered by Medicaid. It coordinates policy development with other departmental entities and health care organizations. It prepares and manages federal Medicaid waivers, prepares budget justifications for program issues, and analyzes the impact of new and amended state and federal laws and rules. The Bureau is also responsible for utilization management and prior authorization of certain Medicaid services. Finally, the Bureau is responsible for designing, advertising, procuring and monitoring services for specific medical care and unique medical utilization reviews via contracts.

This office develops Medicaid policies for:

• Behavioral health services
• Child health services
• Health facility services
• Health practitioners
• MediKids
• Long-term care services
• Home and community-based waiver programs.

In addition, this office performs administrative functions of the Medicaid program and administers medical authorization functions.

The Bureau of Health Systems Development (HSD) is responsible for the development and oversight of Medicaid's managed care programs including managing contracts with and providing policy for HMOs, Provider Service Networks, Minority Physician Networks, the prepaid dental health plan and the MediPass program, Medicaid's primary care case management program. The Bureau also has responsibility for the Disease management Initiative. HSD prepares federal Medicaid waivers, justifications for program issues, and analyzes the impact of new and amended state and federal laws and rules related to managed care. The units included in HSD are:

• Managed Care Contracting and Policy (HMOs and Dental Plans).
• Provider Service Network Contracting and Policy
  Other Managed Care Systems (MediPass, Disease Management, Data Services).
• Special Projects (Waivers, managed care legislation, health plan technical assistance

The Bureau of Pharmacy Services is responsible for managing the Medicaid prescribed drug program. This involves maintaining a clinically and cost-effective Preferred Drug List (PDL) for fee-for-service recipients, managing the manufacturer rebate program which has netted a record cost-savings to the state over the past several years and overseeing the recipient lock-in program to improve coordination of care and prevent fraud and abuse. The bureau also works to ensure that the Medicaid program reimburses drug claims appropriately and has pharmacists placed across the state in area offices to assist prescribers and provide academic detailing and intervention programs to improve quality of care. These are just a few of the responsibilities of this bureau. To learn more, visit the Medicaid Pharmacy Services website.

Medicaid Area Offices

Medicaid has eleven area offices that serve as local liaisons to providers and recipients. The area offices handle claims resolution, provider relations and training, and manage transportation and Child Health Check-Up screenings (formerly known as Early and Periodic Screening, Diagnosis and Treatment) on a local level.