A Fee for Service Medicaid member is defined as either of the following: (1) a member who is not enrolled in an Accountable Care Organization (ACO); or (2) a member who is enrolled in an ACO, but the service that is needed is covered by Medicaid, not by the plan.
Medicaid refers to services not covered in a contract with an ACO or Prepaid Mental Health Plan as ‘carve-out’ services under Fee for Service coverage.
Fee for Service members may receive covered services from any Medicaid provider. The provider must follow Medicaid coverage and prior authorization requirements. The provider submits the claim to and obtains payment from Medicaid. All questions concerning services covered by Medicaid and not covered by the ACO should be directed to the Medicaid Information Line.