People with Medicaid are automatically enrolled in the IBHP. If you get Medicaid, you do not have to pay Magellan. You may have copayments for your medical services. For more information, please see the Idaho Medicaid Health Plan Booklet. 

People with Medicaid may not disenroll from the IBHP, but if you lose Medicaid eligibility, you might be automatically disenrolled. 

To keep getting Medicaid, you will be asked to reconfirm your eligibility every once in a while. This is called re-evaluation or recertification. When you are due for recertification, the Idaho Department of Health and Welfare (IDHW) will notify you and give you the forms you need to complete. If you still meet the eligibility requirements at the time of your re-evaluation, you will continue to receive Medicaid.

To find out when you need to recertify or to update your name, address or other contact information, or your income, call IDHW’s Self-Reliance customer service line at  1-877-456-1233 (TTY 711). Be sure to keep your contact information updated with the IDHW at all times.
 

If you lose Medicaid Coverage While in Treatment

If you are no longer eligible for Medicaid while you are in treatment, please call Magellan as soon as possible at 1-855-202-0973 (TTY 711). We will see if there are other programs you may qualify for. Priority is given to members who actively participate in their treatment over time.

If you are an Idaho resident and do not have Medicaid, you may be eligible for the IBHP if you: 

• Are age 18 or over with a Serious Mental Illness (SMI) or a Serious and Persistent Mental Illness (SPMI), depending on your income
• Are an adult or adolescent member of a priority population who meets diagnostic criteria for a substance use disorder and specifications for care, depending on your income 
• Have been ordered by the court to get mental health services
• Are under age 18, with a mental health diagnosis and substantial functional impairment, depending on the family income 

You may not disenroll from the IBHP, but if you no longer meet these criteria, you might be disenrolled.

You are not eligible for IBHP services if you:

• Do not live in Idaho
• Only have Medicare Savings Program coverage
• Are an undocumented immigrant or are otherwise not legally living in the U.S.
• Are dually eligible for Medicare and Medicaid in one of these plans:*
  • Medicare-Medicaid Coordinated Plan (MMCP)
  • Idaho Medicaid Plus (IMPlus) plan

*Unless you are receiving an IBHP service that is not covered by Medicaid.

If you do not have Medicaid, you are not eligible for IBHP services if you:

• Have any of these conditions but do not have a mental health or substance use disorder: 
  • Neurological disorder
  • Neurocognitive disorder
  • Developmental disability
  • Physical disability
• Have a medical disorder that causes psychiatric symptoms, unless you also have a mental health or substance use disorder 

If you don’t have Medicaid but think you might qualify for it, apply at this website: https://idalink.idaho.gov. You can also call 1-866-456-1233 (TTY 711) or email MyBenefits@dhw.idaho.gov. To learn more about different Medicaid programs, visit this website: healthandwelfare.idaho.gov/services-programs/medicaid- health.

If you haven’t applied for Medicaid, are in the middle of applying, or believe you aren’t eligible, you may still get some IBHP services that are paid for by other programs. You can complete an eligibility screening to see if you can get these services. An eligibility screening is a set of questions Magellan asks to see who is eligible to get IBHP services. You can do an eligibility screening by calling us at 1-855-202-0973 (TTY 711).

You do not need to do the eligibility screening if your treatment is ordered by the court, or in other specific situations that will be directed by the IDHW.

If we find that you are eligible for services paid for by other programs:

• We will help you choose a provider to receive a full assessment. The provider will be in a location that meets your needs and travel preferences. Your provider should give you an appointment for an assessment within 5 days unless this does not meet your timeframe.
• We will pay for your services for up to 30 calendar days while you apply for Medicaid and/or wait for your application to be processed.
• If your application for Medicaid is approved, you will get Medicaid services.
• If your application for Medicaid is denied, you must call Magellan at 1-855-202-0973 (TTY 711). You need to give us your proof of denial so that you can get services paid for by other programs after the first 30 days. Magellan may reach out to you during this time to see if you have the proof of denial. If you get it before they call you, please call us at soon as possible at 1-855-202-0973 (TTY 711).
• If you do not provide the proof of denial within 30 days, Magellan cannot continue to provide your services.
• Whether or not you have Medicaid, if you stay engaged in active treatment, you can continue to get services paid for by other programs as long as you are eligible.

Please note: The money for these services paid for by other programs is limited each year. If there is no money left for these services when you apply, we will give you names of organizations that can help you.

If we find that you are not eligible for services:

• We will tell you and give you names of organizations that can help you.
• You can appeal our decision (see the next section).
• If you have other insurance, you can call them to see what they will pay for.

If Magellan says you are not eligible for IBHP services and you think we made a mistake, you may ask for an Appeal. You must submit your Appeal request to Magellan within sixty (60) calendar days from the date on the Notice of Adverse Eligibility Decision letter.

You can have someone else act on your behalf. If someone else appeals for you, you must give them written permission by completing the Authorization to Release Protected Health Information (PHI) form and sending it to us. You can complete this form online at MagellanofIdaho.com. Look in the Member Handbook and Forms section. You can also download the form from that page to print and fill out.

How do you ask for an appeal?

There are four (4) ways you can ask for an appeal:

• Call Magellan at 1-855-202-0973 (TTY 711)
• Fax the Member Appeal Request Form to: 1-888-656-9795
• Email the Member Appeal Request Form to: IDAC@magellanhealth.com
• Mail the Member Appeal Request Form to:

Magellan Healthcare, Inc.
Attention:  Idaho Appeals Department
P.O. Box 2188
Maryland Heights, MO 63043

You can find the Member Appeal Request Form in the Member Handbooks and Forms section of this website.

If you appeal in writing by fax, email or mail, please send a copy of the Notice of Adverse Eligibility Decision letter you received. You can use the Member Appeal Request Form in the Member Handbooks and Forms section of this website or write a letter that includes:

• The name of the person appealing
• The address and telephone number of the person appealing
• The reasons why you are requesting the Appeal
• Whether you are requesting standard or expedited (fast) Appeal
• Whether you want to keep getting services during the Appeal process

When we receive your Appeal, we will tell you and your provider that we received it by sending you a letter in the mail within five (5) business days.

How long does it take to make a decision about your Appeal?

• Expedited (fast) Appeal: Magellan will determine if you meet the criteria for an expedited Appeal within 72 hours. We will contact you if more time is needed.
• Standard Appeal: We will make a decision within thirty (30) days of getting your Appeal. We will contact you if more time is needed.

If we need more time to review your Appeal, we can ask the Idaho Department of Health and Welfare (IDHW) for fourteen (14) more calendar days. If we need more time, we will tell you about this request by phone and letter within two (2) calendar days of contacting the IDHW. If the IDHW agrees with our request, we will tell you in writing.

Submitting an Appeal and Fair Hearing Request to IDHW

If you disagree with Magellan’s decision about your eligibility Appeal, or if we miss our deadline to make a decision about your Appeal, you have the right to submit an Appeal to IDHW and ask for a State Fair Hearing. You can only ask for a State Fair Hearing once you have finished the Appeal process with Magellan.

You can ask for a State Fair Hearing if:

• You have completed the Appeal process with Magellan and you are still dissatisfied with our decision on your Appeal; or
• You did not receive a Notice of Appeal Resolution Letter within 72 hours from receipt of Appeal for expedited (fast) Appeal; or
• You did not receive a Notice of Appeal Resolution Letter within 30 calendar days from receipt of Appeal for standard Appeal; or
• You did not receive a Notice of Appeal Extension telling you that we needed an additional 14 calendar days to finish your expedited (fast) or standard Appeal request.

What should I send with my State Fair Hearing request?

You may send additional information with your Fair Hearing request. Additional information is not a requirement. You do not have to wait to have the records to request a State Fair Hearing.

Examples of additional information are medical records, doctor’s notes, or financial records that support your reasons for the State Fair Hearing request. Keep your own copies of any documents you send.

You, your provider, or a person you trust can submit the Appeal and State Fair Hearing request to the IDHW. The Office of the Attorney General will hold the hearing. State Fair Hearings are always over the phone. During the hearing, IDHW will be asked to explain why Magellan’s decision was correct. You will be asked to tell the state why you disagree with Magellan’s Appeal decision. Your provider or a person you trust can help you and attend the hearing.

After the hearing, the hearing officer will give you, your provider, and IDHW a final decision within thirty (30) days from the date of the hearing. If the Hearing Officer’s decision is that Magellan’s decision was correct, you may have to pay for services you continued to get during the Appeal and State Fair Hearing process.

You, your provider, or someone you trust may ask for a State Fair Hearing by submitting an Appeal to the IDHW. There are five (5) ways to ask for a State Fair Hearing:

• Mail:

Idaho Behavioral Health Plan Governance Bureau
PO Box 83720
Boise, ID 83720-0009
 

• Deliver to: Your local Health & Welfare office
• Email: IBHPAppeals@dhw.idaho.gov
• Fax: 1-208-364-1811
• Phone: 1-866-681-7062 (TTY 711)

You or someone you trust can ask for a free copy of the criteria, guidelines, or any other information we use to make our eligibility decision by calling 1-855-202-0973 (TTY 711). If you have any questions about this decision, please call Magellan 1-855-202-0973 (TTY 711), Monday – Friday, 8:00 a.m. to 6:00 p.m., Mountain Time.

If you do not have Medicaid, you may need to pay your provider for part of your IBHP services. This is called a copayment.

• Your copayment is based on your income level.
• You may need to give your provider your copayment before you get services.
• Your provider might choose to waive your copayment. If they do, you will not need to pay.
• Native American and Alaskan Native Idahoans do not have to pay copayments.

Please note: Medicaid members may have copayments for their medical services. For more information, please see the Idaho Medicaid Health Plan Booklet at this website: Idaho Medicaid Health Plan Booklet.

You might be able to get health insurance for your youth from the Idaho Children’s Health Insurance Program (CHIP). CHIP is part of Idaho Medicaid and is a health insurance program for youth in low-income families who do not qualify for traditional Medicaid. For more information, visit this website: healthandwelfare.idaho.gov/services-programs/medicaid-health/childrens-health-insurance-program-chip.

You can apply for CHIP at this website: idalink.idaho.gov. You can also call 1-866-456-1233 (TTY 711) or email MyBenefits@dhw.idaho.gov.

If your youth is not eligible for CHIP and/or you need health insurance, visit www.yourhealthidaho.org or call 1-855-944-3246 (TTY 711).