Take a Medicaid Moment: Use Proper Consent Forms
You shouldn’t expect your state Medicaid fund to pay or behave the same as other third-party payers, or even Medicare.
Medicaid is a federal entitlement program incepted through Title XIX of the Social Security Act. The fund is maintained through a blend of state and federal monies, usually on a fixed budget or allotment. The entitlement program provides assistance to individuals and families with low incomes and resources. Medicaid is the largest source of funds for medical and health services for America’s poor.
Know State Eligibility Standards
Under comprehensive national guidelines established by federal statutes, regulations, and policies, each state establishes its own Medicaid eligibility standards; determines the type, amount, duration, and scope of services; sets the rate of payment for services; and administers its own program. Consequently, a person who is eligible for Medicaid in one state may not be eligible in another state, and the services provided by one state may differ considerably in amount, duration, or scope from services provided in a similar or neighboring state.
State rules come from the state legislature and must go through the Centers for Medicare & Medicaid Services (CMS) for approval prior to adoption. The state must then make a policy to reflect how the plan will be implemented. You should be able to locate this on your state Medicaid website, or by calling provider relations.
Use Consent Forms when Applicable
Although Medicaid plans have some “wiggle room” for policy, there are plenty of overarching federal guidelines they must follow to avoid an Office of Inspector General audit and/or lose their federal funds participation. A good example is the requirement to have a signed consent for sterilization prior to performing this type of surgery. Your state’s Medicaid plan will not (nor should they) pay for this without proper consent. The provider performing the surgery should request the consent and place a copy on the hospital chart. Both the anesthesiologist and facility where the procedure is performed could become ineligible for reimbursement if this is not done properly (depending on individual state policy). See the federal requirements around this in the Code of Federal Regulations (CFR) 42 § 441.253 through § 441.258 starting at www.law.cornell.edu/cfr/text/42/441.253.
Another procedure with a non-negotiable consent required is abortion. Abortion procedures are limited to those consistent with the Hyde Amendment restrictions. The Hyde Amendment allows for the use of federal funds for abortions to terminate a pregnancy under two conditions:
- The pregnancy is the result of an act of rape or incest; or
- The life of the mother would be endangered if the fetus is carried to term. (42 CFR 441.203 and Public Law No. 105-78, section 509 and 510, pertaining to revisions of the Hyde Amendment, 1998).
Check with your local Medicaid plan because they may require a standardized consent form for certain procedures. If your claim is denied, you may appeal—but, prior to doing so, review the state plan and any applicable state rules.
Define Medicaid Policy in Writing
When writing policy for Medicaid, you must first define the subject. The following definitions were taken directly from the Code of Federal Regulations (CFR) authority: 42 U.S.C. 1320 and 1395hh. Source: 51 FR 34766, Sept. 30, 1986 (unless otherwise noted).
Medicaid means medical assistance provided under a State plan approved under Title XIX of the Social Security Act.
A Medicaid agency means the single State agency administering or supervising the administration of a State Medicaid plan.
3) State plan or the plan means a comprehensive written commitment by a Medicaid agency, submitted under section 1902(a) of the Act, to administer or supervise the administration of a Medicaid program in accordance with Federal requirements.
a. Sec. 1902. [42 U.S.C. 1396a] (a) A State plan for medical assistance must—
(1) provide that it shall be in effect in all political subdivisions of the State, and, if administered by them, be mandatory upon them;
(2) provide for financial participation by the State equal to not less than 40 per centum of the non-Federal share of the expenditures under the plan with respect to which payments under section 1903 are authorized by this title; and, effective July 1, 1969, provide for financial participation by the State equal to all of such non-Federal share or provide for distribution of funds from Federal or State sources, for carrying out the State plan, on an equalization or other basis which will assure that the lack of adequate funds from local sources will not result in lowering the amount, duration, scope, or quality of care and services available under the plan;
4) Medical Assistance is defined under Sec. 1905 [42 U.S.C. 1396d]. For purposes of this title—
a. The term “medical assistance” means payment of part or all of the cost of the following care and services or the care and services themselves, or both  (if provided in or after the third month before the month in which the recipient makes application for assistance or, in the case of Medicare cost-sharing with respect to a qualified Medicare beneficiary.