Wiki Medicaid out-of-pocket question

[jeffreyneal71]

I know that a non-Medicare provider can charge a Medicare member for a service if there is an ABN in place. But is it the same for Medicaid? I.e., if a Medicaid member (Medicaid only, non-dual) wishes to receive a service from a provider who does not accept Medicaid, are they allowed to pay out-of-pocket and receive the service? I cannot find any definitive answer to this question. It seems to be determined by each state. For instance, I found information online which states that Colorado "state law prohibits providers, including dentists, from collecting fees from Medicaid patients related to a Medicaid-covered service. This restriction applies regardless of whether the provider is enrolled as a Medicaid provider or not." But is that true for all states? I cannot find anything on Medicaid.gov, and I have a friend who works in A/R in Massachusetts who states that if a Medicaid member wants to pay out-of-pocket to see a provider who does not accept Medicaid, they have every right to do so. But it seems strange to me that there is no consistency here across states like with Medicare and the ABN requirement. I work in Massachusetts, and I do not want to be out of compliance here or end up in a situation where we have to return payment to the member because it is illegal. Any help or advice would be greatly appreciated.

 

[kdlberg]

Logically, it seems like it would be okay (in Mass. but maybe not Colorado.) The patient is essentially going out of network, and if it were commercial insurance, the patient would be responsible. Did you try contacting anyone from your state's Medicaid office? I know that might be a giant undertaking--the phones in my state's Medicaid office seem to have "issues"--but I'd want a definitive answer and not just "random internet person used deductive reasoning." Because as we all know, CMS has its own logic which doesn't always match normal logic.

If I were the provider's office, I would have the patient sign that they was informed that no claim would be submitted to insurance and they would be responsible for 100% of the costs. CYA is the name of the game these days.

 

[ckeeney]

Just a note on Medicaid. Medicare is an entirely Federal program and sets nationwide regulations. Medicaid is a joint program between the Federal government and the states. States must follow some rather broad guidelines but there is much discretionary area for state regulation. That is why each state can set these kinds of rules. You should check your state's Medicaid provider manuals or call a provider rep for guidance. If you are not a Medicaid provider that may be difficult. This is what I found: https://www.hca.wa.gov/assets/billers-and-providers/providerone-billing-and-resource-guide.pdf