What if the item is covered, but there is no contracted provider in the area?

There are situations where a needed contracted Medicaid provider is not available within a reasonable distance. The most common situation is when a client is unable to find a Medicaid contracted dentist within a reasonable distance.

An exception to rule (ETR) may be requested. The reasoning must be documented. A medical expense is not allowed at the private rate if the care/expense is available under the Medicaid rate.

ETR requests for a medical deduction listed as a covered item under Medicare, Medicaid, or Apple Health must go through the HCS regional financial program manager for HCS offices. For DDA cases, an ETR request to reduce participation for a covered item must go through HCS HQ Marcie Birdsall.

Example

An exception to rule (ETR) can be considered for any medically necessary (MN) expense to reduce participation if an item is needed right away and the client has requested an appeal through Health Care Authority, Medicare or the Apple Health managed care plan.