Medicaid is a federal program that provides health coverage for low-income families with children, low-income elderly, and disabled people. The federal government and each state share in the cost of Medicaid programs. Each state sets their own perimeters for eligibility which is mostly based on one’s ability to pay for healthcare.

The Medicaid program has recently expanded eligibility to 133% of the poverty level. This was because of the Affordable Care Act's requirement that all must have health insurance or incur a penalty. Children under the age of 21 could also qualify for added coverage under one of their state’s Special Children’s Services programs.

Medicaid plans can be administered by the state, meaning that the state has a separate department that is tasked with the handling of claim related services, including claim processing. Medicaid plans can also be administered by a health insurance carrier, like Blue Cross Blue Shield or United Healthcare, who is acting on the state’s behalf by processing claims for patients with Medicaid.

Medicaid plans normally have some type of pre-authorization requirements which could vary by Medicaid carrier. Some requirements include:

1.      Pre-approval for all services over a stated dollar amount. For example, all services over $500.00.

2.     Pre-approval by procedure. For example, all CT scans or DME supplies.

3.     All services require pre-authorization.

All pre approval requirements must be completed before the patient comes in the office. Most Medicaid plans will not allow a retrospective request; a request for approval after the service was rendered.

Providers who choose to participate with Medicaid, agree to abide by the rules as set forth by the plan and they agree to accept the Medicaid payment as payment in full. Of course, they can expect patients to pay for any copayments (this is rare) or not covered charges.

Medicaid does not have a standard way to administer their plans. This means that you cannot expect that all states will operate exactly the same:

  • Every state has some discretion in the way care is delivered, claims are processed and payments are made.
  • Medicaid plans could range from a Fee For Service plan to a Managed Care plan.
  • Plans could be administered by the state or they could use a health carrier to handle all claim related issues; enrollments, and claim payments.
  • Plan members have the option to choose a traditional fee for service plan or any of the different managed care plan like a PPO or an HMO.

Reimbursement could also range greatly from one state to the next. For example, Medicaid reimbursement is higher in California than it is in Louisiana because the cost to live in California is more expensive. Cost of living is one of the many factors that are used to come up with this pricing data.

Medicaid covered services include:

  • In and outpatient hospital charges
  • Prenatal care
  • Doctor’s services
  • Lab and x-ray services
  • Well child care under 21 years old
  • Family planning
  • Home health care and nursing facilities
  • Other coverages like vision, eyeglasses, prescription drugs, dental, etc., may be available depending upon funding.

Medicaid Eligibility

Medicaid members must first meet the financial requirements in order to qualify for coverage. Those with lower incomes, the unemployed, dependent children or those with a disability may more easily met the Medicaid perimeters for coverage, but those that are employed can also be deemed eligible.

Even if a person’s income exceeds Medicaid’s requirements, that person may be able to qualify for coverage under Medicaid Spend Down. Medicaid Spend Down allows you to use existing medical bills as a way to help qualify for Medicaid coverage.

Spend Down is available only to those:

  • Persons under 21
  • Persons over 65
  • Disabled or blind
  • In some situations where a parent is absent, out of work or deceased.

Once it is determined how much excess income a person has, they can use medical bills to offset the excess.

For Example

It is determined that a person’s income is over the Medicaid requirement by $450.00 but they have just spent $500.00 for new glasses. They can apply this $500.00 to reduce the $450.00 excess income so they would now be eligible for Medicaid coverage.

The ability to spend down to obtain Medicaid coverage may be critical for some patients with serious health conditions and only one health plan leaving them responsible for the huge medical bills.

Back to Chapter Two

Next to Medicare