New York Medicaid Enrollees Cannot be Billed

This note to providers is taken directly from the NYS Healthcare website

www.health.ny.gov/health_care/medicaid/program/update/2007/2007-07.htm#rem

This is a reminder to all Medicaid providers about requirements of the Medicaid Program related to requesting compensation from Medicaid enrollees, including Medicaid enrollees who are enrolled in a managed care plan and in Family Health Plus.

Acceptance and Agreement

When a provider accepts a Medicaid enrollee as a patient, the provider agrees to bill Medicaid for services provided or, in the case of a Medicaid managed care enrollee, agrees to bill the enrollee's managed care plan for services covered by the contract.

The provider is prohibited from requesting any monetary compensation from the enrollee, or his/her responsible relative, except for any applicable Medicaid co-payments.

Private Pay Arrangements

A provider may charge a Medicaid enrollee, including a Medicaid enrollee enrolled in a managed care plan, only when both parties have agreed prior to the rendering of the service that the enrollee is being seen as a private pay patient.

Note that due to the requirement that PRIOR agreement be made for payment, Medicaid enrollees may never be charged for services rendered in the Emergency Room (except of applicable Medicaid co-payments.)

This must be a mutual and voluntary agreement. It is suggested that the provider maintain the patient's signed consent to be treated as private pay in the patient record.

Medicaid Managed Care vs. Medicaid Fee-for-Service

A provider who participates in Medicaid fee-for-service but does not participate in the enrollee's Medicaid managed care plan may not bill Medicaid fee-for-service for any services included in the managed care plan, with the exception of family planning services.

Such a provider may not bill the enrollee for services that are covered by the enrollee's Medicaid managed care contract unless there is prior agreement with the enrollee that he/she is being seen as a private patient as described above.

The provider must inform the enrollee that the services may be obtained at no cost to the enrollee from a provider that participates in the enrollee's managed care plan.

Collections

A Medicaid enrollee, including a Medicaid managed care enrollee, must not be referred to a collection agency for collection of unpaid medical bills or otherwise billed, except for applicable Medicaid co-payments, when the provider has accepted the enrollee as a Medicaid patient.

Providers may use any legal means to collect applicable unpaid Medicaid co-payments.

Emergency Medical Care

A hospital that accepts a Medicaid enrollee as a patient, including a Medicaid enrollee enrolled in a managed care plan, accepts the responsibility of making sure that the patient receives all medically necessary care and services.

Other than for legally established co-payments, a Medicaid enrollee should never be required to bear any out-of-pocket expenses for medically necessary inpatient services or medically necessary services provided in a hospital based emergency room (ER).

This policy applies regardless of whether the individual practitioner treating the enrollee in the facility is enrolled in the Medicaid Program.

Claim Submission

The prohibition on charging a Medicaid enrollee applies when a participating Medicaid provider fails to submit a claim to Computer Sciences Corporation (CSC) or the enrollee's managed care plan within the required timeframe. It also applies when a claim is submitted to CSC or the enrollee's managed care plan and the claim is denied for reasons other than that the patient was not Medicaid eligible on the date of service.

Claiming Problems

If a problem arises with a claim submission, the provider must first contact CSC or, if the claim is for a service included in the Medicaid managed care benefit package, the enrollee's Medicaid managed care plan.

If CSC or the managed care plan is unable to resolve an issue because some action must be taken by the enrollee's local department of social services (e.g., investigation of enrollee eligibility issues), the provider must contact the local department of social services for resolution.

For questions regarding Medicaid managed care, please call the Division of Managed Care and Program Evaluation at: (518) 473-0122.

For questions regarding Medicaid fee-for-service, please call the Office of Health Insurance Programs at: (518) 473-2160.