MedicaidAdministrativeMedium impact
Stop Loss Case Management & Rare-Expensive Case Management
Maryland Medicaid·MD·Hospital
Effective date
Jul 21, 1997
We identified it
Jun 20, 2026
Summary
Maryland Medicaid establishes Stop Loss Case Management for recipients with over $61,000 in inpatient hospital costs and Rare and Expensive Case Management for specific high-cost conditions. Hospitals must verify enrollment status through EVS and follow different billing procedures for each program.
Action Required
Immediately: Hospital billing teams in Maryland must verify patient enrollment status through EVS before admission. For Stop Loss patients (EVS message 'HealthChoice, Stop Loss, call 1-800-565-8190'), obtain pre-authorization for non-emergency admissions and submit DHMH 3808 form with claims. For REM patients (EVS message 'Rare and Expensive, call 1-800-565-8190'), bill Medicaid directly as fee-for-service. Update billing procedures to handle shared financial responsibility between MCO (90%) and Medicaid (10%) for Stop Loss cases.