How Medicaid interacts with other payers : MACPAC

medicaid and other payers

Medicaid interacts with other payers when Medicaid recipients have other sources that are legally responsible for paying their medical costs. These may include private insurance, Medicare, other public programs such as the Ryan White program, workers’ compensation, and amounts received for injuries in liability cases. The program also interfaces with the State Children’s Health Insurance Program (CHIP) when states provide Medicaid coverage to beneficiaries using CHIP funds. In addition, there are circumstances in which state Medicaid programs arrange for another entity to pay providers for Medicaid-covered services, such as through managed care contracts or premium assistance programs.

Reading: Medicaid and private insurance who pays first

When Medicaid benefits supplement another source of coverage, such as Medicare or private insurance, it is often called comprehensive coverage. Providers that accept Medicaid payment for beneficiaries with another source of coverage may, in some cases, charge cost sharing for services covered by both sources, but only up to Medicaid allowable amounts (if any) and only to the extent where the payment from the other source is less than the Medicaid rate. (see Chapter 4 of the March 2013 macpac report). Providers are prohibited from charging beneficiaries cost-sharing for Medicare Part A and Part B services provided to certain persons who are dually eligible for Medicare and Medicaid.

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In most cases, Medicaid acts as the payer of last resort for most services. Under the program’s third-party liability (tpl) rules, other legally responsible sources are generally required to pay medical costs incurred by a beneficiary before the medicaid program does. As a condition of eligibility, Medicaid members must identify potential sources of third party coverage and assign the Medicaid agency the right to pursue third party liability on their behalf. Exceptions include certain prenatal and pediatric services, for which Medicaid may pay and then claim reimbursement. There are also cases where Medicaid can pay for services that might otherwise be funded by other public agencies or programs, either because they are designated by law as payers of last resort after Medicaid (such as Ryan White Hiv/Aids, Title V Health Maternal and Child Block Grants, Indian Health Service, and Individuals with Disabilities Education Act programs) or are not considered legally responsible third parties (such as schools and public health or child welfare agencies fulfilling their general responsibilities to ensure access to necessary medical attention).

In addition to interacting with other payers on a TPL basis, Medicaid may arrange for private plans and other entities to pay providers for Medicaid-covered services. For example, most Medicaid enrollees receive at least some of their benefits through managed care plans, which contract directly with states and must meet requirements that are specific to the Medicaid program and its population. In contrast, under premium assistance programs, which have historically had limited enrollment but whose use is now growing, states can pay for coverage from the private market (usually offered through exchanges or employers) that was designed to serve a Population that does not have Medicaid. Under a separate statutory provision of other Medicaid premium assistance authorities, states are required to pay Medicare Part B (and, in some cases, Part A) premiums for certain beneficiaries who are dual eligible for both programs.

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