All about Medicaid

State Insurace Medicaid – An operations study

Medicaid is a federal and state plan, operated by the states, which is an entitlement program under the Social Security Administration of the federal government for patients whose income and resources are insufficient to pay for healthcare.


The Medicaid program, jointly funded by the State and Federal governments, provides medical benefits to individuals with low income and resources. It is run by the individual States under broad Federal guidelines. Each state

1) Establishes its own eligibility standards
2) Determines the type, amount, duration, and scope of services
3) Sets the rate of payment for services
4) Administers its own program

Consequently, the Medicaid program differs widely from state to state. It even differs from region to region within a State, since local bodies are also involved in the funding and implementation of the program. Coverage, billing and reimbursement rules also change over time.

Though each state has discretionary powers to set its own eligibility standards, States are required to provide Medicaid coverage to most individuals receiving federally assisted income maintenance benefits, and for related groups not receiving such cash assistance.

Aid to Families with Dependent Children (AFDC)

Recipients of AFDC and Supplemental Security Income (SSI) are all eligible for Medicaid. They receive federal cash assistance. Besides, other disadvantaged groups, who satisfy the AFDC and SSI program criteria, but who do not receive cash assistance are also eligible. Poor children and low-income pregnant women, both of whom are some of the largest beneficiaries of Medicaid, are examples. Some states also include non-disabled adults without children in the Medicaid eligible groups.

Medically Needy Eligibility Groups

Some groups may not satisfy the low-income standard. That is, their income may make them ineligible for Medicaid. But they can still become eligible by "spending down". This means that a person may have an income above the poverty level indicated by the state's Medicaid program. But high medical expenses may offset this margin. When the medical expenses are reduced from the person’s income that person may fall below the poverty level. This is called spending down and thus the person become eligible.

Another way a person becomes part of the medically needy group and qualifies for Medicaid is by paying the state an amount equal to the difference between family income and the income eligibility standard.

Suppose a person's income is $100.00 above the income eligibility level. The person does not qualify. But by paying $100.00 to the state, after deducting any medical expenses he/she has incurred, he/she becomes eligible. The amount, which keeps him/her above the poverty level, is surrendered to the state. Only Medically needy individuals resort to this method. Their incomes will not be low enough to qualify for Medicaid, and not high enough to help them meet their medical needs.

Different states apply different income and resources methodologies to decide on the poverty level i.e. the methods they adopt to measure income/resources level and thus decide on Medicaid eligibility differ widely.

Medicaid Benefits for Medicare Beneficiaries

For certain poor Medicare beneficiaries, called "Qualified Medicare Beneficiaries" (QMB) with incomes below the Federal poverty level and with resources below twice the standard allowed under the SSI program, Medicaid will pay the Part A and Part B Medicare premiums and co-insurance.
"Specified Low-Income Medicare Beneficiaries" (SLBM), those that have marginally higher incomes than the QMBs, Medicaid will pay the Medicare Part B premium only.

Claims Submission & Payment

Federal Law requires Medicaid to accept CMS 1500 for claims processing in states where optical scanning facility is not available. Some states like New York and Georgia have special forms developed exclusively for claims processing by their state and which has optical scanning facilities. Though the Health Care Financing Administration (CMS) of the Department of Human Services of the US Government is responsible for administering Medicaid, each State Government has its own requirements and they append to what CMS determines. Hence claims submission in some states may go directly to Department of Human Services, while in some states it goes to county department of welfare and so on.

Medicaid carriers in almost all states have the facility of receiving claims electronically.

Filing Limit – This is the period within which claims need to be submitted failing which claims would be denied for lapse of time. Some Medicaid carriers have this as 1 year from date of service while some have this as 90 days from date of service and so on.

Other insurance plan – It is to be ensured that the patient has no other coverage other than Medicaid. If he has one and it is still valid, then we need to submit it to that coverage first.

Crossover – Crossover is a process wherein claims are automatically being sent to the supplemental carriers by Medicare after Medicare processes the primary claims and makes payment to the providers. The supplemental carriers processes and make payment to the providers. Some Medicaid carriers would have this facility. Here the provider need not have to submit a fresh claim to the secondary carrier.

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