Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 7: Service Management


States require PCPs to directly provide or authorize through referral a full range of Medicaid services. Chart O illustrates services commonly provided or authorized by the PCP in the eight case-study states. These states uniformly include primary and preventive services; however, several states allow Medicaid beneficiaries to obtain EPSDT services, immunizations, OB/GYN services, and family planning services from providers other than their PCPs without a referral. These states commonly exclude dental, mental health/substance abuse services, residential care, and long-term care services.

State Program Services
Chart O:
Services Included in PCCM (Provided or Authorized by PCP)
Alabama Patient 1st Physician, services, excluding dental and family planning, outpatient hospital services
Florida MediPass Hospital, lab, x-ray, EPSDT, immunization, family planning
Iowa MediPASS Physician, hospital, lab, x-ray, EPSDT (no authorization required), immunization, home health, durable medical equipment (DME), hearing
Maine Maine PrimeCare Physician, hospital, lab, x-ray, chiropractic, audiology, DME, EPSDT, home health, optometry, physical/occupational/speech therapy, podiatry
MaineNET/ Partnership All Medicaid services (including pharmacy, mental health)
North Carolina ACCESS I Physician, hospital, lab, x-ray, skilled nursing, EPSDT, immunization, family planning, durable medical equipment, hearing, hospice
Oklahoma SoonerCare Choice PCCM Model Physician, lab, x-ray, EPSDT, immunization, case management
Texas Texas Health Network Physician, hospital, lab, x-ray, case management, skilled nursing facility, EPSDT, immunization, family planning, home health, mental health (no referral or prior authorization needed except for inpatient psychiatric)
Virginia MEDALLION Physician, hospital, lab, x-ray, home health, EPSDT, DME, OB/GYN (no referral required)

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