Medicaid for New Attorneys
This paper provides the new attorney with an overview of the Medicaid program?its administration, eligibility and service rules. While each state must adhere to the federal Medicaid Act?s minimum requirements, there is much room for flexibility. Therefore, it is important to become familiar not only with the federal rules but also with the policies guiding the program at the state level.
Medicaid can be complex. For in-depth information about the program, please consult our Advocate?s Guide to the Medicaid Program. We are also available to consult with you on any question that you have about the program?s operation federally or in your state. Please do not hesitate to contact us.
Introduction
Medicaid is the program of medical assistance for individuals with limited incomes established by Title XIX of the Social Security Act.2 Medicaid covers one in six people.3 It is the largest source of insurance for children, covering nearly one in four.4 This paper covers the following topics:
- Administration of the Medicaid program
- Medicaid eligibility
- The scope of covered benefits
- Provider participation and managed care
- Key issues and resources for dealing with them
Sources of Information on Medicaid
- Medicaid Act ? 42 U.S.C. §§ 1396 et seq.
- Medicaid Regulations ? 42 C.F.R. §§ 430 et seq.
- CMS, State Medicaid Manual, available at http://www.cms.hhs.gov/Manuals/01_Overview.
- CMS, Dear State Medicaid Director Letters, available at http://www.cms.hhs.gov/SMDL/SMD/list.asp#TopOfPage and www.www.healthlaw.org
- CMS transmittals, see www.www.healthlaw.org
- Federal and state court cases
- State statutes and regulations, health plan and provider contracts, and policy letters
- State Medicaid Plan, link through http://www.cms.hhs.gov/medicaid/stateplans/
- State case worker and provider manuals
Administration of the Medicaid program
Since its enactment in 1965, Medicaid has been an ?entitlement? program. This means that individuals who meet Medicaid eligibility requirements have a legal right to have payments made to their providers for the covered services they need.
While state participation in Medicaid is voluntary, all states participate. States also have an entitlement?to receive federal matching payments for all state spending on covered services. Federal payments do not come without strings attached, however, as states must adhere to minimum federal requirements when implementing their Medicaid programs.5
Administration of the Medicaid program at the federal level is the responsibility of the Centers for Medicare and Medicaid Services (CMS), of the United States Department of Health and Human Services.6 In addition to promulgating Medicaid regulations, CMS publishes the State Medicaid Manual and Dear State Medicaid Director letters that announce federal Medicaid policy.
Federal law requires each state to designate a ?single state agency? to administer its Medicaid program.7 This means that each state must have in effect a written state Medicaid plan that has been approved by the federal government.8 The state plan describes who is eligible for Medicaid, what services are covered, and how the program is administered. In general, the state?s Medicaid program must conform to all requirements of federal law9 and operate statewide.10
States must provide that all individuals wishing to apply for Medicaid can do so without delay and ensure that assistance will be furnished with reasonable promptness.11 States must also establish a Medical Care Advisory Committee, which includes Medicaid beneficiaries and knowledgeable providers, to advise the single state agency on policy development and program administration and to review marketing materials of Medicaid-participating managed care organizations.12
Through matching payments, the federal and state governments fund the Medicaid program. In some states, counties or local governments also contribute toward the state costs. Federal matching payments can vary from fifty percent to eighty-three percent of the total expenditures, with poorer per capita income states receiving higher federal payments.13 Federal spending accounts for 57 percent of all Medicaid spending.14
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