Working with Medicaid

Working with Medicaid The Medicaid program is for low-income people. The Medicaid program is financed by the federal government and the states. The Medicaid program is the nation’s largest non-employer-sponsored health insurance program. In order for a person so be eligible for Medicaid benefits, the must meet the minimum federal requirements and any additional requirements of the state in which they live. Medicaid rules vary from state to state and are frequently changing. Due to the variations in Medicaid rules from state to state, a person would need to contact their local social services department to find out what procedures and services are covered and not covered. Depending on what state a person lives in, those enrolled in the Medicaid program may be treated by a provider of their choice or it may restrict patients to a network physicians. Enrollees may have to receive all services through their primary care provider that is responsible for coordinating and monitoring their care. Those that need to see a specialist may need to obtain a referral from their PCP or Medicaid will not pay for the services. If a Medicaid enrollee wants to receive a service that is non-covered, the enrollee must pay for the non-covered services prior to the services being rendered. Medicaid recipients can also be billed if the physician informed the patient before the service was performed that the procedure/service would not be covered by Medicaid, the physician has an established written policy for billing non-covered services that applies to all patients, the patient is informed in advance of the estimated charge for the procedure and agrees in writing to pay the charge. If the physician has reason to believe that a service will not be covered, the patient must be informed in advance and given a form to sign acknowledging this. However, some states may require the enrollee to pay a small co-pay for covered services. Implications of simultaneous federal and state involvement in the insurance process could cause conflict between state regulations with federal regulations. The cost of compliance is more likely to be greater because there are two regulating bodies. Complexity is increased due to satisfying the requirements of two regulatory bodies. Regulatory goals of the states may be different than the federal goals which in turn lead to a duplication of effort.