Demystifying the layers of state Medicaid

July 19, 2018 | Holly

It can be challenging to understand the many layers of Medicaid plans, the state funded insurance.  Let’s demystify some of these layers. I will explain a little more about three common plan types of state Medicaid. There are more than three types, but for this discussion we will focus on “fee for service”, and CCO (very similar to HMO), and state Medicaid with federal Medicare.

Let me state that even though you may not have any intention to serve state Medicaid patients, a basic step in building a strong foundation for your medical or behavioral health practice is to complete the credentialing and enrollment process for state Medicaid.  This will not obligate you to see state Medicaid patients.  It is not a contract. It will, however, open some options for you and function as a safeguard for when you find you’ve been seeing a state Medicaid patient unknowingly.  You can gain the upper edge by having that enrollment in place.

In this article I refer to “state” Medicaid and “federal” Medicare because people often get these two confused and I want to be sure you are aware they are very different and not the same coverage at all.  Also, I am generally referring to Oregon Medicaid, however, Medicaid functions very similarly in every state.

A primary way I preserve my sense of humor while dealing with insurances is by adopting a game plan view.  I strive towards scoring a win over the insurance companies by getting them to issue payment for provider claims.  Some are more difficult than others, and when I achieve this goal I sure feel like it’s a win.  I mean – “SCORE”!  Am I right?

I understand these three layers like this:

Medicaid – Fee for service:  Fee for Service can be viewed as a gateway, because if a provider is not credentialed and enrolled with “fee for service”, they will not be recognized as a valid provider by any of the other types of state Medicaid plans.  Fee for service is often referred to as “open card”.  Patients are free to seek treatment anywhere in the state, if they can find a provider who will treat them.  Being on “open card” is normally very brief, usually less than a few weeks. The state Medicaid office pushes hard to roll these patients over into CCO managed care plans as quickly as possible.

Medicaid – CCO plans:  These plans are very similar to HMO’s and prior authorization is often required. These are managed care plans, administered by a variety of other insurance companies, and in some cases managed by counties. Providers may request to contract with these plans and get on their panel of preferred (in network) service providers.  If the panel is full, their request may be rejected.  Patients have less freedom to choose who they see, as the plan they are on has a limited panel of contracted (in network) providers.

Some examples of state Medicaid CCO plans are IHN CCO (Intercommunity Health Network CCO) which is administered by Samaritan Health Plan, Jackson Care Connect CCO which is administered by CareOregon, Allcare CCO, PacificSource CCO, Trillium CCO, Willamette Valley Community Health CCO, and Healthshare CCO which further delegates plan administration to various county offices.  This list can go on and on.

These plans can be difficult to identify.  Watch for “CCO” anywhere on the card. Look at the policy number which will still be the patient Medicaid number.  Use the state Medicaid web portal to look the patient up.  If they have any form of state Medicaid plan, they should be found on this web portal.

One caveat is that Medicaid will often retro activate coverage backwards in time up to three months.  You could check today and not find coverage for a patient, and you could check the same patient tomorrow and find their coverage goes back three months in time.  If you have questions about what you find on the web portal, you can place a phone call.  However, avoiding long hold times seems to be a thing of the past.

Medicaid in conjunction with Medicare: 

Sometimes state Medicaid will pay the monthly federal Medicare premium for the patient. State Medicaid could pay claims as secondary after federal Medicare pays as primary.  Or, the patient could be on a federal Medicare Advantage plan (again think HMO with prior authorizations often required and limited panel or in network providers).  When it comes to federal Medicare always look for the word “Advantage”.  The word “Advantage” on any insurance card is going to tell you federal Medicare is in the picture.   “Advantage” or “Med Advantage” always indicates federal Medicare (whether there is state Medicaid involvement or not).

Again, get very familiar and routine with using the state Medicaid web portal. Don’t be shy about calling to ask for help interpreting what you see there.  Before trying to bill these claims, you would need to be credentialed and enrolled with federal Medicare, state Medicaid, and credentialed and possibly contracted with the administering insurance company. That could possibly be three enrollments just to bill one claim.

Let me reiterate, you will not be obligated by credentialing and enrolling with   state Medicaid “fee for service”.  However, you will then qualify for payment if you happen to see an “open card” patient.  Or, you could qualify for out of network payments from a CCO plan if you discover you have unknowingly been treating a patient on one of these plans, given you obtain prior authorization.  Sometimes the CCO’s will do retro prior authorizations.

Patients sometimes change insurance plans and forget to inform their provider office.  If one of your existing patients switches to a state Medicaid plan, being credentialed and enrolled will allow you to be recognized as a valid provider.  You could potentially see a patient many times before realizing they are on a state Medicaid plan.  Depending on how far out your claims are, or who is working your aged reports, it could be a long time.

In closing, remember that credentialing and enrolling in fee for service state Medicaid will not obligate you, and is not a contract.  It will provide a safeguard and open some options.

I always welcome questions.  It’s easy to reach me, Holly at 503.508.5643.