How Does Medicaid Work
The Medicaid program does not provide health care services for everyone. Your application will be reviewed for all Medicaid programs. If you are found eligible for Medicaid, you will get:
- A letter in the mail from Medicaid telling you about your coverage
- A Medicaid ID card
- A Healthy Louisiana plan ID card, if you enroll in a plan.
Each time you go to your health care provider or pharmacy, take your Medicaid ID and Healthy LA plan ID cards with you. Show them at all medical visits before you receive any service. The health care provider or pharmacy will tell you if they accept your Medicaid benefits. You should also ask your health care provider or pharmacy if the service or prescription is covered by Medicaid before receiving the service or filling a prescription.
Medicaid does not pay money to you instead, it sends payments directly to your health care provider or pharmacy.
Medicaid Is Structured As A Federal
Subject to federal standards, states administer Medicaid programs and have flexibility to determine covered populations, covered services, health care delivery models, and methods for paying physicians and hospitals. States can also obtain Section 1115 waivers to test and implement approaches that differ from what is required by federal statute but that the Secretary of HHS determines advance program objectives. Because of this flexibility, there is significant variation across state Medicaid programs.
The Medicaid entitlement is based on two guarantees: first, all Americans who meet Medicaid eligibility requirements are guaranteed coverage, and second, states are guaranteed federal matching dollars without a cap for qualified services provided to eligible enrollees. The match rate for most Medicaid enrollees is determined by a formula in the law that provides a match of at least 50% and provides a higher federal match rate for poorer states .
Figure 2: The basic foundations of Medicaid are related to the entitlement and the federal-state partnership.
Transferring Medicaid Benefits To Another State
Technically, theres no formal program or option that allows you to transfer your Medicaid coverage from one state to another. Therefore, if youre relocating, youll need to reapply for Medicaid in the new states.
The good news is that youre allowed to apply for Medicaid in your new state immediately after relocating, and doing so can help you avoid a lapse in benefits. It generally takes anywhere from 15 to 90 days to receive a letter of approval once you apply for Medicaid, and you can usually submit your application online.
One thing you should know about Medicaid is that you cant be covered by it in two different states at the same time. Therefore, to transfer your coverage so to speak youll need to first terminate your original Medicaid coverage and then apply in your new state once youve relocated.
Most states offer retroactive Medicaid coverage, which allows you to receive coverage for up to three months prior to the date of your applications approval. However, you may be forced to pay for healthcare services out of pocket until that retroactive coverage kicks in and renders you eligible for reimbursement. To this end, make sure to retain copies of all medical receipts for services received during your coverage gap.
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How Do I Apply For Medicaid
You can apply for Medicaid at any time.
Even if you applied by mail, in-person, or over the phone, you can create an online account to check the status of your application, report household and address changes, request a new Medicaid ID card, and renew your Medicaid coverage.
Most Medicaid Enrollees Get Care Through Private Managed Care Plans
Over two-thirds of Medicaid beneficiaries are enrolled in private managed care plans that contract with states to provide comprehensive services, and others receive their care in the fee-for-service system . Managed care plans are responsible for ensuring access to Medicaid services through their networks of providers and are at financial risk for their costs. In the past, states limited managed care to children and families, but they are increasingly expanding managed care to individuals with complex needs. Close to half the states now cover long-term services and supports through risk-based managed care arrangements. Most states are engaged in a variety of delivery system and payment reforms to control costs and improve quality including implementation of patient-centered medical homes, better integration of physical and behavioral health care, and development of value-based purchasing approaches that tie Medicaid provider payments to health outcomes and other performance metrics. Community health centers are a key source of primary care, and safety-net hospitals, including public hospitals and academic medical centers, provide a lot of emergency and inpatient hospital care for Medicaid enrollees.
Figure 6: Over two-thirds of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs.
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What If I Am Not A U S Citizen
To be eligible for Medicaid in Louisiana, you must be resident of Louisiana and either U.S. citizen or a non-citizen who is lawfully present in the U.S. Non-citizens can qualify for coverage for emergencies and labor and delivery services if income requirements are met.Medicaid and LaCHIP coverage may be available to children up to age 19 who are lawfully residing and are otherwise eligible.
Medicaid Coverage Has Evolved Over Time
Under the original 1965 Medicaid law, Medicaid eligibility was tied to cash assistance or federal Supplemental Security Income starting in 1972) for parents, children and the poor aged, blind and people with disabilites. States could opt to provide coverage at income levels above cash assistance. Over time, Congress expanded federal minimum requirements and provided new coverage options for states especially for children, pregnant women, and people with disabilities. Congress also required Medicaid to help pay for premiums and cost-sharing for low-income Medicare beneficiaries and allowed states to offer an option to buy-in to Medicaid for working individuals with disabilities. Other coverage milestones included severing the link between Medicaid eligibility and welfare in 1996 and enacting the Childrens Health Insurance Program in 1997 to cover low-income children above the cut-off for Medicaid with an enhanced federal match rate. Following these policy changes, for the first time states conducted outreach campaigns and simplified enrollment procedures to enroll eligible children in both Medicaid and CHIP. Expansions in Medicaid coverage of children marked the beginning of later reforms that recast Medicaid as an income-based health coverage program.
Figure 3: Medicaid has evolved over time to meet changing needs.
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Hcbs 1915 Waiver Programs
Through certain waivers, states can target services to people who need LTSS. These waivers are called home- and community-based services 1915 waivers.
All of the HCBS 1915 waiver programs:
- Are fee-for-service programs, meaning that the provider is paid for each service the patient receives
- Require individuals to meet criteria set by the state and based on level of need
Traveling Out Of State With Medicaid
If you travel outside of your home state and get sick, Medicaid generally doesnt cover the cost of services you get on your trip. Generally, the care you get must be provided to you in your home state to be eligible for Medicaid coverage. One major reason for this limitation is the way providers bill Medicaid. As a rule, a medical provider in one state will only be authorized to bill that states Medicaid. Thus, an outpatient clinic you visit in Kansas probably cant collect payment from Medicaid in Texas.
There is one major exception to this rule: out of state Medicaid coverage may be used if you have a life-threatening emergency. This must be an emergency that requires immediate medical care, and there isnt time for you to return home to receive care from your regular provider.
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Using Original Medicare In Another State
You dont have to do anything to use Original Medicare in another state. You will want to update the address that Social Security has on file for you.
You can use your Original Medicare benefits in another state if you visit any health care provider who participates in the program.
Medicare participation in any state can be broken down into three categories:
What If I Think A Decision You Make Is Unfair Incorrect Or Made Too Late
You have the right to appeal the Medicaid decision. There are several ways to request an appeal. You can write the reason you disagree with the decision on the back of the decision letter and then mail or fax it to Medicaid as directed on the letter. You can also fax the decision letter to the Division of Administrative Law at 225-219-9823 or mail it to the Division of Administrative Law, Department of Health Section, P. O. Box 4189, Baton Rouge, LA 70821-4183. You can request an appeal by phone by calling Medicaid Customer Service at 1-888-342-6207 or the Division of Administrative Law at 225-342-5800.
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How Does The Medically Needy Spend
Medically Needy provides Medicaid eligibility to qualified individuals and families who may have too much income to qualify for regular Medicaid programs. Individuals and families who meet all Medicaid program requirements, except that their income is above those program limits, can spend-down or reduce their income to Medicaid eligibility levels using incurred medical expenses.
Health Insurance Premium Payment
The Health Insurance Premium Payment program is a Medicaid program that helps families pay for private health insurance. This program is for families who have:
- A parent or a spouse with private health insurance
- A child or a spouse with Medicaid
Medicaid will pay the family’s private health insurance if the total cost of that insurance is less than the total cost of care with Medicaid. The total cost of the private insurance includes the premium, coinsurance and deductibles.
If approved, Medicaid may pay the private health insurance costs for the entire family and not just for the family members who get Medicaid. The family will get services through the private health insurance plan.
To learn more or to apply, visit the Get HIPP Texas website or call us toll-free at 800-440-0493. You also can ask us to send you an application. Write to:
Texas Health and Human Services CommissionTMHP-HIPP
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Child Health Management Services
Medicaid or ARKids First-A : If a child under 21 is found to have a health problem or is not developing normally, Medicaid or ARKids First-A will pay for many different services. These can include medical, psychological, speech and language pathology, occupational therapy, physical therapy, behavioral therapy, and audiology. The purpose is to find out whats wrong and how to treat it, to keep it from getting worse and affecting the childs future. To receive these services, you will need to get your primary care doctors okay, called a referral.
ARKids First-B does not offer the CHMS program, but some of the same services are covered if needed. A PCP referral is required.
How Medicaid Coverage Works When You Move
You should reapply for Medicaid benefits as soon as you can to avoid a lapse in benefits coverage when you relocate across state lines. While the application process varies by state, you can usually apply online. In most cases, you’ll receive a letter of approval within 15 to 90 days.
Another thing to keep in mind is you can’t get Medicaid benefits in two states at the same time. Instead, you have to terminate your old Medicaid coverage in one state and reapply for benefits in your new home state.
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A Warning For Medicaid Beneficiaries Traveling Out Of State
Access to affordable health care through the Medicaid program is one of the great benefits afforded to most recipients of Supplemental Security Income . In many states, full Medicaid coverage is often equal to, or even better than, many private health insurance plans, allowing SSI beneficiaries and other Medicaid recipients to effectively manage their illness or disability.
However, many Medicaid recipients dont realize that their health insurance coverage generally will not provide a full set of benefits should they require care while out of state.
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City, State
For example, some states may cover only out-of-state emergency room services in life-threatening situations that require immediate care, when there simply isnt the time for the injured person to return safely to their home state.
Should a beneficiary need to be admitted to a hospital in another state, or if they must receive essential, regular psychiatric care or medications from an out-of-state provider, the home state will not pay for the services through Medicaid. In these situations, a caregiver or other family member is often required to sign an agreement to pay for the services before the person with special needs can receive care.
Getting Preapproved
It may be possible to get preapproved Medicaid coverage at an out-of-state facility, but the patient would need to obtain proper authorization .
Know the Rules
Medicaid Spending Is Concentrated On The Elderly And People With Disabilities
Seniors and people with disabilities make up 1 in 4 beneficiaries but account for almost two-thirds of Medicaid spending, reflecting high per enrollee costs for both acute and long-term care . Medicaid is the primary payer for institutional and community-based long-term services and support as there is limited coverage under Medicare and few affordable options in the private insurance market. Over half of Medicaid spending is attributable to the highest-cost five percent of enrollees. However, on a per-enrollee basis, Medicaid is low-cost compared to private insurance, largely due to lower Medicaid payment rates for providers. Analysis shows that if adult Medicaid enrollees had job-based coverage instead, their average health care costs would be more than 25% higher. Medicaid spending per enrollee has also been growing more slowly than private insurance premiums and other health spending benchmarks.
Figure 9: Medicaid per enrollee spending is significantly greater for the elderly and individuals with disabilities compared to children and adults.
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Medicaid Coverage Is Determined By The State
Part of the confusion surrounding Medicaid coverage is the federal nature of the program. While Medicaid is funded by the federal government, the program operates as a joint partnership with the states. Each state is responsible for setting its own Medicaid guidelines, including eligibility, covered services, service waivers, and other factors. As a result, possessing Medicaid through one state in no way guarantees that you will be covered when traveling to another state.
Instead, each state sets its own rules about when out-of-state services will be covered. It will be up to the state that provides your Medicaid to determine what services will be covered out of state and under what circumstances. For example, if you are a Florida resident covered by Florida Medicaid, you can obtain coverage for an out-of-state medical visit so long as you obtain a referral from your Florida physician. The out-of-state provider, in turn, must be willing to accept Florida Medicaid payment. You might also need to obtain prior authorization before the treatment.
How To Change Your Address With Medicare
If you are a Medicare beneficiary and move to another state, you can change your address that’s on file with Medicare by contacting the Social Security Administration .
Here are some ways you can contact the SSA:
- Visit the SSA website and submit an address change notice through the website.
- Visit your local SSA office in person.
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Can You Use Out Of State Medicaid In Florida
Clients frequently ask us: If I have Medicaid from another state, will I be covered in a Florida hospital? Or, conversely, will my Florida Medicaid cover me if I am injured in another state? Medicaid is a federal program, so it stands to reason that it would apply across state lines. Unfortunately, the answer is more complex. Below, we discuss how out-of-state Medicaid is treated in Florida healthcare facilities. Call an experienced West Palm Beach Medicaid and asset protection attorney with any questions or for help obtaining medical coverage in Florida.
How Do I Replace My Medicaid Id Card
Call Medicaid Customer Service at 1-888-342-6207 to request a new card or visit the online Medicaid Self-Service Portal. You can create an online account at any time. Until you receive your new card you should call your health care provider before your appointment to make sure they can verify your coverage.
If you need a new Healthy Louisiana plan ID card, call the member services department for a replacement card.
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How To Transfer Medicaid Between States
Using Medicaid Out of State
Find Medicaid Planning Lawyers
You might be wondering if you can usde your Medicaid coverage in any state? The answer is No. Because each state has its own Medicaid eligibility requirements, you can’t just transfer coverage from one state to another, nor can you use your coverage when you’re temporarily visiting another state.
Should a beneficiary need to be admitted to a hospital in another state or if he must receive essential, regular psychiatric care or medications from an out-of-state provider, the home state will not pay for the services through Medicaid. In these situations, a caregiver or other family member is often required to sign an agreement to pay for the services before the person with special needs can receive care.
How long does it take to transfer Medicaid to another state?
Technically, there’s no formal program or option that allows you to transfer your Medicaid coverage from one state to another. Therefore, if you’re relocating, you’ll need to re-apply for Medicaid in the state you’re planning to reside in.
A common concern is the lapse of benefits between canceling ones Medicaid plan in their original state and reapplying in the state in which they are relocating.
You can also consider hiring aTexas Elder Law Attorney specializing in Medicaid planning to help with the process.
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