MEDICAID 101

Medicaid is insurance coverage provided to patients, primarily based upon income.   Medicaid is also provide to patients based upon some conditions regardless of income;  such as developmental delays, autism, several mental illness. and pregnancy.  A patient must routinely be re-certified to maintain their eligibility for coverage.

When a patient is first enrolled in Medicaid, they are issued a state ID card, or Access card.  Within about 90 days, the patient must enroll in a Medicaid HMO who will administer their claims and coverage.  Common Mediciad HMO’s include Gateway, Unision, and UPMC 4 U.  All behavioral health Medicaid services are processed through Community  Care Behavioral Health (CCBH) or Value Behavioral Health. 

For providers, they must be credentialed through the state e-Promise program to be eligible to provide services to a Medicaid recipient.    This gives them the ability to bill and be paid by Access.  The provider must also then be enrolled in the appropriate Medicaid HMO’s in order to bill and be paid by that organization.   Medicaid is a state program and is not a managed care network.  All providers who meet the eligibility criteria are able to be enrolled in Medicaid.  The Medicaid HMO’s are managed care organizations and they often limit the number of providers that they will credential based upon population density in a county.    There is no requirement for any HMO to allow a provider access to their network. 

Each Medicaid HMO has different authorization requirements and benefits for their patients.  Once a provider is enrolled with  a Medicaid HMO it is important that they understand their contractual requirements for authorizations and timely filing.    Additionally each Medicaid HMO has a different fee schedule.  This information is also provided with the provider’s credentialing contract.

There are some very important things to keep in mind when billing for Medicaid, whether it is the Access plan or a Medicaid HMO:

• Medicaid is always the payor of last resort.  This means that all claims must be submitted to personal insurance carriers before it is submitted to Medicaid.    If a provider is out of network with a patient’s personal insurances, the claims must still be submitted to obtain a denial;
• If the patient has personal coverage, the Explanation of Benefits from that carrier must be submitted with the Medicaid claim;
• Medicaid claims have a very narrow timely filing window, generally 90 days.  If there is personal insurance, this timely filing window starts the day the primary insurance processes the claim (i.e., the date on the EOB);
• Medicaid will pay for services up to their allowance, less what was paid by any personal insurance.  For example, if the allowance for Medicaid is $50.00 and primary insurance paid $60.00, there will be NO payment made by Medicaid.  If the allowance for Medicaid is $50.00 and primary insurance paid $40.00, there will be a payment made by Medicaid of $10.00;
• In certain circumstances, if the provider does not participate with the patient’s Medicaid HMO, it may be possible to be paid by the state Medicaid plan.  However, it is still necessary to bill any personal insurance and the Medicaid HMO and submit those denials for consideration;
• If you are a Medicaid provider, YOU CANNOT BALANCE BILL THE PATIENT.  In the signing of your contract you  have agreed to this, and there are no exceptions. 

For the most part, Medicaid will not pay you enough to build a successful practice.  But with many specialties and populations it is an important part of servicing your customer base.