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Balance billing rules Medicaid

This blog Balance billing rules Medicaid will provide details on billing for those with Medicare and Medicaid.  It is also useful for those with Medicaid only. This information may help to prevent future out of pocket costs associated with health care.

Balance billing rules Medicaid and Medicare Advantage plans

A number of Medicaid eligible members also have a Medicare advantage plan.  Medicare advantage plans are co-pay based plans with a network of providers.  Those enrolled in Medicaid will not need to pay the co-pays on the Medicare advantage plan if the provider they see is participating with Medicaid. If the provider is not participating with Medicaid, they will have a co-pay for the services.  There are plans called Dual Eligible Medicare Advantage plans that work a bit differently.  If the provider participates with the Dual Advantage plan, the insured will not be responsible for a co-pay.  This is true even when you go to a doctor this not participating with Medicaid. This rule gives members access to doctors  who are not currently participating with Medicaid without a cost share.

Balance billing rules with Original Medicare and Medicaid

Those with Original Medicare A and B and Medicaid can go to any provider that participates with A and B.  If the provider does not participate with Medicaid, they are not allowed to bill the insured for the Medicare cost share.  Providers not with Medicaid do have the ability to refuse to see that member if they choose however.

Overall

Non Medicaid providers not being able to bill Medicare and Medicaid dual eligible members can be a positive in some situations.  This is because it allows members access to a wider range of providers.  Some providers will simply not be willing to see dual members any longer and as a result, this trend is increasing. Dual eligible plans help to expand access to providers and may have extra benefits such as dental and vision.  On the other hand, if the dual plan does not have a specific doctor in network, the member will not be able to see them.  They would be able to see that same provider if on Original Medicare only.

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