By enrolling in the Medicaid program, a provider agrees to accept Medicaid payments as a full payment for the services provided. A provider cannot enter into a private wage agreement with a recipient to accept a Medicaid fee for a specific service covered, then offer another updated service (usually a service that exceeds the scope of the Medicaid program) and only charge the recipient the difference in the fee between two services, in addition to Medicaid`s billing for the covered service. It is unacceptable to knowingly demand or recover a supplementary reimbursement of the Medicaid rights, unless the law allows it. What if my state does not have „command and right“ status? Can I register and be under a private contract? Private contract – Is it legal for a CPD physician to enter into private contracts with a Medicaid patient for covered benefits? usually. Unfortunately, recent changes to Medicaid in the Affordable Care Act (which apply even if your state has not expanded Medicaid) make it difficult to answer this question. Unlike Medicare, where doctors have to actively opt-out to make it legal to privately accept „covered services“ with patients, in the case of Medicaid, if you have not formally „signed,“ the assumption is that you are not enrolled in the program and that you are free to enter into private contracts with Medicaid patients for covered services. There are state exceptions to this general rule, and Kentucky is one of the most monstrous examples (where an earlier executive decision of the governor made it illegal to enter into private contracts with Medicaid patients in one way or another). Make sure you do your homework! In 2014, AAPS had an excellent Q-A exchange with CMS, during which cms made it clear that they currently felt there should be no problem with the awarding of private contracts with patients with Medicaid. Other states, such as Missouri, have made it clear that such private contracts are allowed. For more information on the DURB, see: www.health.ny.gov/health_care/medicaid/program/dur/index.htm. A provider who does not participate in Medicaid service charges but has a contract with one or more managed care plans to serve Medicaid Managed Care or FHPlus members cannot charge Medicaid a service fee for services. Similarly, a provider cannot charge a recipient for benefits covered by the recipient`s Medicaid Managed Care or FHPlus contract, unless there is a prior agreement with the recipient to be considered a private salaried patient, as described above.
The provider must inform the recipient that benefits can be obtained free of charge from a provider participating in the recipient`s managed care plan. The above information contains more specific billing details to support the drug billing instructions in the 5010 special edition update of Medicaid 5010 www.health.ny.gov/health_care/medicaid/program/update/2011/feb11mu_special.pdf February 2011. If there is a disagreement with the MCO provision, the applicant or the rightful person may file an appeal against the plan. A supplier can file an appeal on behalf of a participant, with the appropriate consent. The participant is also entitled to a claim and may be the subject of an external claim. The supplier also has appeal rights on its own behalf. Note: Due to the requirement to enter into the PRIOR reimbursement agreement, Medicaid recipients should never be charged for emergency services (excluding existing Medicaid supplements). Do you have any comments and/or suggestions on this publication? Please contact Kelli Kudlack by email at: medicaidupdate@health.state.ny.us. Transition The recommendation for a long-term placement in a care home is made by the medical care physician or clinical peer on the basis of medical necessity, functional criteria and the availability of services in the Community, in accordance with current practice and regulations.