Medicare and Medicaid are both government-run healthcare programs that assist people in obtaining health coverage, but the similarity between these two programs end here. The reimbursement mechanisms for Medicare and Medicaid vary a lot depending on the program and the state. On the other hand, Medicaid is a useful program that pays for medical treatment for people who cannot afford it.
Because Medicaid coverage can be enforceable for up to three months, a Medicaid claimant or a member of the family who compensated the applicant’s medical expenses may be able to get refunded. The refund can be made for a few of the home health care costs and other hospital expenses they accumulated and paid in the three calendar months before applying for Medicaid.
It’s also possible to receive reimbursement for home healthcare expenditures incurred in-between when you apply for Medicaid and the time you start receiving services.
Who Can Claim Medicaid Reimbursements?
Medicaid is a federal and state-funded program that helps low-income people pay for healthcare. Although each state determines who is eligible for benefits, the program usually includes those with a low income, such as:
- Individuals aged 65 and up
- Women who are pregnant
- Children under the age of 19
- Adults without children who are financially reliant
- People who have a handicap
- Parents or other individuals who are responsible for children
- Eligible immigrants
Different Medicaid Models
Medicaid reimbursement systems vary from one state to another, but there are a few similarities. However, before we get into the reimbursement procedures, people must understand the various Medicaid models:
- The Fee-For-Service Model
Each provider receives a defined payment in exchange for the services delivered under the Fee-For-Service (FFS) model. FFS rates are intended to compensate doctors solely for the services that a person has received. Consequently, doctors do not benefit from this trade due to dealing with patients who have private health insurance.
Fee-for-service providers are paid based on the number of services they deliver to Medicaid clients. States set their Medicaid payment rates using fee-for-service models, but officials must use the following federal procedures to set the prices:
- Expenses connected with delivering healthcare services.
- Rates for business payers are being reviewed.
- Percentage of Medicare’s reimbursement for comparable services.
Medicare reimbursement systems across regions are dominated by fee-for-service payment. According to the Medicaid and CHIP Payment and Access Commission (MACPAC), a fee-for-service payment model accounted for more than half of Medicaid spending in 2015.
For at least part of its government programs, 38 states and the District of Columbia have converted their Medicaid plans to managed care during the last few decades. Connecticut, Oklahoma, and Vermont are among the twelve states that do not.
Because reimbursement is based on quantity instead of the quality of care, the Fee-for-Service model incentivizes healthcare professionals to deliver potentially unnecessary treatments by reimbursing hospital invoices or medical expenses for itemized costs.
- The Managed Care Model
More states are resorting to managed care services to control Medicaid costs due to the Affordable Care Act. Currently, over 70% of Medicaid beneficiaries are participating in Medicaid-managed patient care networks.
Rather than focusing on individual treatments, managed care services evaluate the patient as a whole. That implies Medicaid pays the very same amount regardless of the services the person receives. The total is then divided by the number of services provided. When a person receives a small number of services, the operators can charge more for each service. The providers will be paid less per service if they have got a multitude of services.
In general, there are three types of Medicaid managed care programs.
- For starters, some states utilize a complete risk-based managed care system in which plans are reimbursed based on a capitated fee for Medicaid-covered treatments.
The monthly fixed sum is intended to cover a specified set of services for the beneficiary. Nevertheless, if the cost of care exceeds the capitated level, the plans take the financial risk. Thus, providers in the integrated risk-based managed care model might be compensated either on a fee-for-service basis or by sharing the model’s economic burden.
According to MACPAC, roughly 54% of Medicaid users were treated under a plan incorporating complete risk-based managed care in 2013.
- Limited benefits plans, which cover 49.5% of participants, are also prevalent. States that have chosen this managed care option collaborate with restricted benefit plans to deliver services to certain patient populations or administer specified benefits.
For example, the restricted coverage plan might target particular services like inpatient mental health, non-emergency healthcare transit, dental health, or chronic disease management.
- Third, just 12.7% of Medicaid recipients are assigned to primary care case management models. A monthly case administration charge is paid to primary care physicians who serve these patients.
This payment method guarantees that patients do not receive medically unnecessary treatments while still obtaining the high-quality care they require. However, there is fear that individuals will not obtain the care they require because doctors believe their present payment is insufficient.
These rates are typically set by the number of individuals registered in the system. Still, these can also be changed based on factors like the Medicare Economic Index (MEI) and state-specified Medicaid inflation modification rates.
Home Care Expenses Reimbursement
Medicaid, a health insurance program for low-income and asset-holding individuals, is one of the few insurance programs covering long-term homecare. As a result, it’s quite typical for persons with assets over the Medicaid asset limitation to spend their money on home care services before applying for Medicaid home care after their resources are below the limit.
The processes for receiving home care compensation in New York City are outlined in this document. In addition, a reference to relevant case law is included in the document. According to a state order issued in November 2010, Medicaid will only compensate Medicaid providers for the period after the filing of the Medicaid application.
This isn’t easy in cities such as New York City, where Medicaid personal care/home caretaker providers cannot be recruited for private-pay services.
Many agencies also run a “Licensed Home Care Services Agency” (LHCSA) privately funded but are not Medicaid participants. However, certified Home Health Organizations, which have increased prices because they involve rigorous nurse supervision, are the only home healthcare agencies that are Medicaid providers and privately paying.
Expenses Not Related to Home Care Reimbursement
Other sorts of medical expenditures incurred and paid for during the retroactive period — the three calendar months preceding the month of the application — can be repaid to a Medicaid applicant (or their family or another person who paid their expenses).
Submit a request with photocopies of the invoices, evidence of payment (canceled checks, credit card payments, and invoices), and the Medicaid notification proving that Medicaid was authorized and the effective date to request compensation for these expenditures.
Authorities are evaluating government programs to enhance treatment quality for beneficiaries while decreasing healthcare costs, from the possible repeal of the Affordable Care Act to the possibility of Medicaid block grant financing. The move away from fee-for-service appears to be here to stay, and clinicians can expect Medicare and Medicaid payments to increasingly fall within alternative payment models.