What if a client chooses a non-Medicare/Medicaid contracted provider?

If a client chooses to go to a non-Medicaid contracted provider or outside the Apple Health managed care network, the charge is the client's responsibility as the service is covered under their Medicare, Medicaid, or Apple Health managed care plan. Health Care Authority (HCA) has an agreement to pay for health care services that is signed by the provider and client. HCA 13-879 The exception is when a client has "creditable" insurance coverage through their retirement, pension, employer sponsored plan or COBRA continuation plan. These client's may have copayments. These copayments are an allowable deduction only if Medicaid does not pay the copayments due the provider not having a Medicaid contract. Individuals with creditable insurance coverage are not limited to Medicaid contracted providers. An exception to rule (ETR) may be requested through the HCS Regional Designee for HCS cases or Marcie Birdsall for DDA cases if a client goes out of network due to special circumstances.