Your Information Source for Medicaid Regulations and Compliance

Filed under: Medicaid Regulations  -    Pinned  | Spread the word !

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Welcome to MedicaidRegulations.net where we offer information regarding Medicaid regulations and related topics. It is our pleasure to garner your interests in Medicaid regulations and compliance and provide additional resources to understand the topics discussed. Medicaid regulations are an important facet of the government’s participation in public assistance and must be followed to ensure that fair coverage is given to all qualifying Americans. Improper coding can lead to incorrect charges or denial of claims for patients which could end up causing problems for both the healthcare establishments with the government and the patient gaining extraneous debt.

Public Assistance programs such as Medicaid are designed to offer help to low income families and individuals who cannot afford their healthcare. This is provided as a joint federal and state program that is regulated by the government. Eligibility standards are defined by each state and can affect the benefits that patients can receive with the coverage. The adherence of payment rates for the 56 programs stemming from the different states, territories and District of Columbia must be followed by each patient as outlined in their terms. Medicaid regulations must be followed by healthcare services in coding to properly grant the needed claim imbursement.

Compliance standards must be met to prevent or reduce the need for federal investigation to claims placed into the Medicaid system. Improper coding of Medicaid claim charges may impact the healthcare provider, employees and facilities in a negative manner. Illegal Medicaid claims for services not rendered can even lead to imprisonment for offenders. To learn more about Medicaid regulations, subscribing to the Compliance Watch Newsletter provides you with leading information about Healthcare Compliance and other issues. Use the form at the end of this post to subscribe to the Compliance Watch Newsletter.

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Battle on Medicaid Expansion Continues

Filed under: Medicaid - 18 Jul 2013  | Spread the word !

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The healthcare reform is still experiencing a lot of problems. The Medicaid expansion plan is under debate, and it looks that the battle continues. The State Senate has been working for weeks now on the Medicaid extension plan in conjunction with the Affordable Care Act, but they have failed to come to an agreement.

Senator Randy Richardville recently claimed that even though the healthcare plan was debated in the Senate, no conclusion has been reached. Senators have not finished their work.


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“The workgroup is making good progress, but they do not yet have a draft to review. As soon as that information is available, we will distribute and then meet again to receive testimony,” the Senate majority leader claimed according to Woodtv.com

“I have a lot of confidence in this process and I expect that we will have a better product to consider in the very near future,” he added.

While the Senate seems incapable of taking a decision, impatience grows around the country. Michigan is one of the states which awaits for a decision to be taken. Senator Richardville promised he will offer an update on the work of expanding Medicaid coverage to between 300,000 and 500,000 people in this American state. No answers have been given until today. Senators still hope that they will be able to reach a conclusion, at least on the Michigan matter, before the break.

However, full Senate action is expected in early fall. If Medicaid expansion plan will be voted, and in which form, is something we will probably find out by the end of the year.

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Medicaid Extension Approved in Illinois

Filed under: Medicaid Regulations - 31 May 2013  | Spread the word !

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The state of Illinois has passed the bill to extend Medicaid coverage. This means that now, all low-income residents of the US state may become eligible for Medicaid coverage. The Medicaid reform bill has been passed by the Illinois Senate on Tuesday. Soon, uninsured low-income residents here, regardless of their parental status, may enjoy the coverage.

This bill will not only expand access to health care for the uninsured, it will also strengthen our efforts to transform Illinois’ health care sector into a wellness system that focuses on preventative services and provides better quality treatment when people do become sick,” the governor of the state, Pat Quinn claimed. The politician also said that he will sign the bill, who will soon become a law on the territory of the state.


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Currently, the state offers Medicaid coverage to low-income residents. However, there is a limitation on this aspect. Low-income residents are defined as all those earning less than 133 percent of the federal poverty line, but only in case they are parents to children below the age of 18.

If the changes will be made according to what the new law states, over 350,000 Illinois residents will receive coverage. This extended coverage will be funded by the government for the first three years. Later on, the state will have to submit about 10 percent of the sum needed to cover such a great number of people.

The bill is considered to be a huge step for all residents of the state of Illinois. This will most likely lead to the improvement of the healthcare services offered to low-income residents. It is a well known fact that people who have no insurance usually wait too long until seeing a doctor for the health problems they are experiencing.

People without insurance will gain access to Medicaid as soon as the law will enter in effect. In the end, this is great for the entire community.

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Medicaid Expansion Plan May Not Be Approved

Filed under: Useful Information - 26 Apr 2013  | Spread the word !

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The Medicaid expansion plan proposed for vote in the United States remains unpopular in a great number of states. Until today, only 20 states have voted the plan, while 15 are against expanding. The remaining states are not decided, but most seem to lean to a negative vote.


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Why is the expansion plan rejected by such an impressive number of states? Well, it seems that governors believe that Medicaid expansion is not a great idea, even though it may initially look like being a great plan that will provide health insurance of hundreds to thousands of people in each American state. For instance, the government of Pennsylvania believes that expanding Medicaid next year as part of the federal Affordable Health Care Art would benefit the insured individuals, but also the economy of the state. This means that at state level, the savings will be greater. The federal government will be responsible with covering 100 percent of the additional costs for the first 3 years, after which the state will pay 10 percent.

This is just one position on the Medicaid expansion plan, which has managed to cause virulent debates all around the country. Still, things in the healthcare industry in the United States are more complicated. Medicaid, which has always been an insurance program for low-income families and individuals, will become available for people with incomes up to 138 percent of the federal poverty level, in case the expansion will be accepted. However, the entire plan is considered to be extremely risky by some healthcare leaders. The new changes may not work, being by far too complex for the population who will have to understand them.


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Despite opinions and claims made by officials in each state of the country, what everyone should know is that Medicaid expansion will bring some new costs on state level. If all states expand, costs are estimated to increase to $41 billion by 2022. The savings that states can make will probably be dwarfed by costs, as specialists predict. It has been widely claimed that states who have opted for Medicaid expansion can change their mind in case the federal government fails to fulfill its commitments. Well, according to analysis having a change of heart would be impossible once the expansion is adopted.

Overall, the expansion of Medicaid would mean that millions of Americans will benefit of healthcare coverage. Naturally, the benefits that can be obtained in this context are enormous. Still, there are costs and risks that the critics of this reform argue to overshadow all benefits. The debate on Medicaid reform has been on for months now and it surely seems that a conclusion will not be reached in the near future.

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Frequently Asked Questions On Medicaid

Filed under: Medicaid - 19 Feb 2013  | Spread the word !

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Medicaid is nowadays one of the most important healthcare programs functioning on the territory of the United States. This is a healthcare program that aims to offer coverage to families with low incomes and limited resources. Millions of Americans benefit today of Medicaid, fully enjoying medical coverage. These are the people who otherwise would not afford paying for healthcare. To be able to learn more about Medicaid, and be aware of all rules and regulations that apply to this program, here you will find a list of the most frequently asked questions on this public assistance program.

1. What is Medicaid?

As already mentioned, Medicaid is a healthcare program that currently functions on the territory of the United States. This program has actually been created with the main purpose to offer health coverage to people who otherwise cannot afford to pay for medical care.


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2. Who is eligible for Medicaid?

This actually is a complex question. There are many categories of people who can become eligible under the terms of Medicaid. They are low-income beneficiaries of Medicare, children who are aged under 21, women who have been diagnosed with breast cancer or cervical cancer, children who suffer from disabilities, but also workers with disabilities, as well as children in foster care or subsidized adoption, pregnant women and parents of caretakers or deprived children. Of course, these are just the general categories of people who can become eligible for Medicaid. Another important requirement that should be mentioned in this context is being a citizen of the United States or a permanent resident of the country.


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3. How to qualify for Medicaid?

If you know that you fall at least under one of the aforementioned categories of eligible people, you should apply for Medicaid health coverage. How to apply? Well, you should know that this process is not complicated at all. However, you will have to offer a proof of pregnancy, situation, citizenship or income, depending on your case and the category you subscribe to. You will also have to fill out the application form. Providing documentation regarding your current situation will offer you the possibility to qualify for Medicaid.


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There are numerous benefits that can be enjoyed when using Medicaid health coverage. If you are, or at least if you think you may become eligible for it, there is no reason to avoid applying. There are huge chances for you to benefit of this great program, as well.

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Important Information On Medicaid Regulations And Eligibility

Filed under: Medicaid Regulations - 29 Jan 2013  | Spread the word !

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Being in a good state of health is not an option, it actually is a must. Health is extremely important to all of us. When you have reasons to suspect that something may be wrong with your health, you need to seek medical assistance. Naturally, to be able to overcome the conditions you are suffering from, you have to receive the best treatment, the highest quality medical care and constant support.

Medicaid is a healthcare program that currently functions on the territory of the United States. This healthcare program was actually created with the purpose to offer health coverage to people who otherwise cannot afford paying for it. Under the current regulations of Medicaid, there is a variety of people who can use these services. They are the individuals aged over 65, people who suffer from a permanent disability, as well as individuals who have been diagnosed with blindness.


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Still, it is important to know that besides the aforementioned categories, there are also other people who can receive medical coverage due to the use of Medicaid. They are listed below:

  • Low-income beneficiaries of Medicare;
  • Children up to 21;
  • Women with breast or cervical cancer;
  • Children with disabilities;
  • Workers with disabilities;
  • Children in foster care or subsidized adoption;
  • Pregnant women;
  • Parents of caretakers or deprived children.


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Another important criterion you will have to meet in order to receive Medicaid coverage is to be a citizen or a permanent resident of the United States. Actually, this is the main aspect that will be checked when it comes to Medicaid eligibility. Income may also be used in determining if an individual is eligible for this program or not. Of course, to become a beneficiary of Medicaid you will have to provide all documentation needed to prove that you fall under at least one of the above mentioned categories.

In fact, to be able to apply for Medicaid you will have to fill out an application form, but you will also have to provide documentation to verify general and financial requirements. Your submission will be analyzed by Medicaid specialists and you will be notified if you are eligible or not. Generally, this entire process takes about 45 days.


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Now that you know which are the main rules and regulations that apply to Medicaid, you can take a decision on whether it would be a good idea to submit your application or not. In case you think that you could be eligible for the program, you should apply for it as soon as possible.

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Medicaid Regulations Related To Transportation

Filed under: Medicaid Regulations - 21 Nov 2012  | Spread the word !

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One element of federal Medicaid regulations is that each state implements a plan to assure transportation assistance for Medicaid recipients in order to benefit from health care. There are also Medicaid regulations for transportation that allow states to claim federal matching funds for necessary transportation as an optional Medicaid service, administrative expenses or even both.


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Those states that provide necessary medical transportation services as optional medical service must pay directly to a Medicaid-approved vendor. Thus, the Medicaid recipient has some choice in choosing a transportation vendor, but only if costs are not exaggerated.

Even when it’s an optional medical service, states still must use any sources of free transportation that are available. Then, the federal matching funds for such transportation costs will be reimbursed at the same rate as the state’s Federal Medical Assistance Percentage. This is determined under Section 1905(b) of the Social Security Act.


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If medical transportation is handled as an administrative expense, states must use the least expensive means, including free services also or even volunteer services. Instead of a direct payment for transportation costs a state can provide bus tokens and gas vouchers. Additionally, federal funds will be provided for 50 percent of the administrative rates.


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Related to regulations for children’s transportation, all the states must provide transportation as a medical service for children receiving Medicaid, even this is not available for adults. There are also regulations that allow costs for travel-related expenses such as lodging and meals and also an adult that accompanies the child.

Medicaid recipients that need information on transportation resources in their local area have to contact a member of the Area Agencies on Aging (AAA). Contact details for all AAA members are available at the website for the National Association of Agencies on Aging.

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Medicaid Eligibility Requirements

Filed under: Medicaid - 19 Oct 2012  | Spread the word !

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Medicaid is a health program functioning in the United States. The program was designed with the main purpose to offer health coverage to people in need, who cannot afford it otherwise. There are many categories of people who can benefit of the healthcare program.

There are some general Medicaid eligibility requirements that need to be met in order to benefit of the coverage. There also are certain requirements that will vary from one state to another. General requirements include:

  • Being over 65 or older;
  • Having a permanent disability;
  • Suffering from blindness.


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Medicaid offers coverage to:

  • Children in foster care or subsidized adoption;
  • Children with disabilities;
  • Children up to 21;
  • Pregnant women;
  • Women with breast or cervical cancer;
  • Parents of caretakers or deprived children;
  • Workers with disabilities;
  • Blind and disabled people;
  • People aged 65 or older;
  • Low-income beneficiaries of Medicare.

Children aged under 19 who become eligible for Medicaid remain eligible for a period of one year. Pregnant women remain eligible throughout the entire pregnancy and about 60 days after the pregnancy ends. 


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In order to receive Medicaid coverage you have to be a citizen of the United States or a permanent resident of the country. Adults aged between 21 and 65 who are not disabled or caretakers of deprived children are less likely to be covered by Medicaid, as they cannot qualify for the program.

Depending on their incomes, individuals may become eligible for Medicaid coverage. In fact, financial requirements can be divided into two main components. They are income and resources. All programs will take income as a factor in determining eligibility. Only some use resources, too.


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To be able to benefit of Medicaid coverage you will have to provide proof and documentation such as the following:

  • Proof of pregnancy;
  • Proof of citizenship;
  • Proof of income.

Qualifying for Medicaid is actually a very complex process. There can be cases in which people with the lowest level of income are not able to qualify for the program.

To apply for Medicaid you need to:

  1. Fill out the application form;
  2. Provide documentation to verify general and financial requirements;
  3. Go through a functional eligibility assessment.


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You can apply yourself for Medicaid coverage, but you may also designate someone in your family to complete this task for you. There will be some eligibility questions asked in the forms, so the person who will fill them out has to be perfectly aware of your current status. You may be asked to offer documents such as current tax bill, real estate appraisal and copies of the mortgage, in case you are in such a situation.

All states have local Medicaid eligibility offices where you can file applications. Most commonly, an agency will need 45 days to process it. The Medicaid agency located in the area in which you live is the only one that can determine if you are eligible or not. In case you are not eligible for Medicaid, you will receive a letter from the agency in which the reason of denial will be explained. You can appeal the decision in case you desire.

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Medicaid and the Children’s Health Insurance Program

Filed under: Medicaid - 28 Sep 2012  | Spread the word !

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Medicaid is the United States health program for people and families with low incomes and resources. This means-tested program is jointly funded by the state and federal governments, but it is managed by the states. Medicaid is also the largest source of funding for medical and health-related services for people with limited income in the United States.


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You and your family may qualify for free or low-cost health insurance coverage through both Medicaid and the Children’s Health Insurance Program (CHIP). These programs provide health coverage to about 60 million Americans, including children, pregnant women, parents, adults, seniors, and disabled individuals.

Who is eligible for Medicaid?

In order to profit from health coverage provided by coverage, the applicants must be U.S. citizens or legal permanent residents. Low-income adults, their children, and people with certain disabilities are the main people served by Medicaid. However, poverty alone does not necessarily qualify someone for Medicaid. Eligibility for this program is based on income and other circumstances. Each state sets its own Medicaid eligibility rules, but generally all states provide health coverage to the following people:

  • Children in families with incomes up to $44,100 per year (for a family of four) are generally eligible for Medicaid coverage and CHIP; however, families with higher income can also qualify for these services in some states.

  • Pregnant women with family incomes up to $19,565 (for a family of two); many states provide coverage for women with incomes up to $27,214, though.
  • Parents; in this case, income limits vary by state.
  • People with disabilities; in nearly all states, Medicaid covers people with incomes up to $1,868, but this figure can go up to $10,890.
  • Beginning on January 1, 2014, adults under the age of 65 with family incomes up to $14,484 will also be eligible for Medicaid services in every state.

What Does Medicaid Cover?

Medicaid provides coverage for a wide array of health problems and provides patients with numerous benefits, including:

  • doctor visits
  • emergency care
  • hospital care
  • vaccinations
  • prescription drugs
  • long-term care
  • vision
  • hearing
  • preventive care for children

Each state offers coverage for these services and many states also provide additional services through their Medicaid programs. If you want to learn more about Medicaid in your state, click
here.

The Childrens Health Insurance Program (CHIP)

CHIP provides low-cost health insurance coverage for children in families earning too much income to qualify for Medicaid, but cannot afford private health insurance. The program provides free or low-cost coverage for about 8 million children up to age 19. Each state establishes its own eligibility criteria, but generally, families with incomes up to $44,100 per year (for a family of four) are likely to be eligible for CHIP coverage.


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In many states, family with higher incomes and their children can still qualify for this program. Children get free preventive care, but low premiums and other cost sharing may be required for certain services. If you want to learn more about CHIP in your state, click
here. When it comes to CHIP, all states cover:

  • routine checkups
  • immunizations
  • hospital care
  • dental care
  • lab and x-ray services

Now that you know the benefits of Medicaid and CHIP and are aware of the eligibility criteria that come with these services, you can easily apply for health coverage. After being connected to someone from your state who will help you apply, you can complete the application and provide the necessary documents through the mail, over the phone, or even online.

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Medicaid For Pregnant Women

Filed under: Useful Information - 03 Aug 2012  | Spread the word !

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Medicaid is one of the most important health programs in the United States of America. Included in it are many categories of poor, disabled and disadvantaged people that cannot afford to pay for medical insurance or the medical insurances that they have don’t cover their needs completely. Poverty is not a standard requirement for people to enter the program. There are certain rules and regulations that people that apply to the program must respect. The general rules of Medicaid are established by CMS, also known as Center for Medicaid Services, but the program is personalized in every state, according to laws and rules available in it. For pregnant women, there are special programs included in the main Medicaid program, which offers them medical care through the pregnancy and also after birth.


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Medicaid offers financing for nearly a half of the births in the United States of America. In the insurance offered to pregnant women is included prenatal care (medical checks during the pregnancy), labor and delivery care and also post-partum care for a period of 60 days. This insurance practically covers costs related to the health of future American mothers and that of their newborn children.

Many states in America extended their coverage in order to offer medical care to pregnant women. In some cases, future mothers who wouldn’t normally be eligible are included in the Medicaid program if their expenses are very high. After women are received in the program, they can benefit of medical care offered with the help of Medicaid through all the pregnancy and 60 days after the end of it, basically until the children are two months old. Even if changes appear in the family income, they are still included in the program. The newborns become automatically eligible for Medicaid and they are not required to have citizenship documentation. Their eligibility is available until the first birthday. In the Medicaid program, babies born my mothers who have this type of insurance are known as “deemed newborns”.


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In some states of America, women who enter Medicaid during their pregnancies may be elected for full medical coverage, but basically they have standard services at their disposal. Even if their pregnancies have complications, all expenses are covered by the program. The 60 days in which they are still insured after the births include even perinatal care.

For pregnant women who cannot afford paying the huge medical expenses which come along with the pregnancy and with the joy of giving birth to a baby, Medicaid is a great chance. And at least until the babies have their first anniversary, they have a lot of benefits. After this period, it all depends on the mothers. If you are in the position of applying to the Medicaid program or you know someone who may need to enter the Medicaid program subscribe to our newsletter to make sure you have all the information you need.

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Medicaid Regulations on HIV

Filed under: Medicaid Regulations - 19 Jun 2012  | Spread the word !

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The climate of health care regulatory enforcement is constantly changing nowadays. A reason behind this fact may be the damaged state of the economy, since the global financial crisis has affected even the most powerful governments in the world. The concern of most people is related to healthcare services, since most of them are under financial distress and do not know what healthcare provider to turn to. Medicaid is the health program in the United States that can help low-income people and families in the United States profit from medical and health-related services. There are numerous Medicaid regulations covering this service, which is why you need to seriously get informed on the subject.

Where do people with HIV stand, though? HIV is a lentivirus that causes acquired immunodeficiency syndrome (AIDS), a condition in humans which leads to the progressive failure of the immune system, while allowing for life-threatening infections and cancers to develop. Medicaid was the main provider of federal money on healthcare for people living with HIV/AIDS. However, things changed when the new Medicaid regulations were implemented. One of the most important Medicaid regulations is Medicare Part B, which specified that the prescription drugs for those eligible for both Medicare and Medicaid shifted to Medicare alone. The new Medicaid regulations also specified that people living with HIV must progress to AIDS (T-cell count drops below 200) before qualifying for Medicaid assistance.

The Medicaid regulations also state that they can only be eligible for the Medicaid services if they have a low income, are HIV positive, and meet some other eligibility criteria. These Medicaid regulations come in contrast with the Journal of the American Medical Association guidelines, which clearly states that therapy is recommended for all patients with T-cell counts of 350 or less. Since HIV medications come at a very high price, many people living with this condition are not able to begin any course of treatment without being helped by Medicaid. However, it is estimated that more than half people living with AIDS in the United States will receive Medicaid payments, the other programs providing financial support to people with this condition being the Social Security Disability Insurance, and the Supplemental Security Income.

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