The government provides a Medicaid card to persons who cannot afford healthcare. The Medicaid card entitles the recipient to low-cost healthcare and prescription drugs.
Beneficiaries must select a primary physician to manage their care. This primary physician is the first point of contact for most non-urgent medical matters. The primary physician is also the one who refers the patient to specialty care providers if a patient is diagnosed with a particular ailment.
Some states offer Medicaid through what is known as a Medicaid Managed care plan. This type of care consists of a network of health care providers and facilities that have contracted with the agency to offer services at reduced rates. Once approved for Medicaid, beneficiaries must recertify annually to determine if they still meet the eligibility criteria for the program. The Medicaid program is mostly successful due to efforts to combat Medicaid fraud to ensure healthcare dollars are spent on those who need it.
A Medicaid card entitles the cardholder to low-cost healthcare and prescription drugs at approved providers. The program sends the card in the mail once the individual is authorized for the program. The recipient must then sign the card and keep it in a safe location. Beneficiaries must first find and designate a Medicaid doctor to serve as their primary care physician (PCP). The PCP coordinates care for the beneficiary and serve as the first point of contact for most medical concerns. If a patient requires specialty care beyond what the PCP offers such as orthopedics or cardiology, the physician refers the patient to a specialty doctor.
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After learning how to use the card, beneficiaries must use providers that accept the insurance as Medicaid only pays for services provided by an approved physician. Patients must ensure the provider they wish to see is one of the approved Medicaid providers before making appointments. If the beneficiary seeks treatment from an unapproved provider, the patient may get a bill for services not covered by Medicaid.
Although prescription drug coverage is an optional benefit, most state Medicaid agencies offer it as a standard benefit. In most states, the program only covers the generic version of the drug unless it was preauthorized by Medicaid. Patient’s may not use their Medicaid card for over the counter medications that could otherwise be purchased over the counter.
Medicaid managed care refers to a type of insurance aimed at lowering health care costs for both patients and providers. The Medicaid managed care plan consists of a network of providers and facilities contracted with Medicaid. Participants in the network have agreed to offer Medicaid beneficiaries services at reduced costs. As such, recipients must use providers within the network for Medicaid to cover the service.
The program is offered through a variety of healthcare plans available to beneficiaries, depending on the state. Beneficiaries may select an insurance plan of their choice; however, they should consider a few factors before making their decision. First, they must ensure that the doctor they wish to see is in the network. Also, the beneficiary must consider the type of services required by their family and select the plan which offers those benefits. Lastly, program participants should choose a plan that has Medicaid providers near their location. Doing so ensures the beneficiary does not ignore health issues or avoid seeking care just because the Medicaid managed care provider is not convenient for them.
In some instances, beneficiaries qualify for both Medicare and Medicaid. The difference between Medicare and Medicaid is that Medicaid is a needs-based program. Medicare on the other hand primarily serves those over 65 years of age and those with specific disabilities. Also, Medicaid is free, while Medicare requires participants to pay monthly premiums and deductibles. For some individuals, based on their income, Medicaid may pay for their Medicare premiums.
Program participants must undergo Medicaid renewal every year to verify their continued eligibility. Medicaid renewal is necessary to ensure the program only pays for coverage for those who qualify. All recipients must undergo the renewal, and no one is exempt. When a beneficiary’s renewal period nears, the Medicaid program sends the beneficiary a renewal packet. The packet contains the steps necessary and the documentation required to renew their coverage.
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When completing the Medicaid renewal form, applicants must provide updated information about income, age, disability status and citizenship status. Beneficiaries may renew Medicaid coverage online or by mainlining the form.
Beneficiaries must complete the renewal process within the time allotted. Failing to resubmit the form could cause the individual to lose their benefits. Once a beneficiary loses their benefits, they must submit a new application for Medicaid and requalify for the program.
If the Medicaid recertification determines that the beneficiary is no longer eligible for the program, the individual may submit an appeal. During the appeal, the individual may present their case to a hearing officer to discuss why their benefits should continue. After the hearing, the officer decides on the final ruling individual’s benefits status.
Providers and patients commit Medicaid fraud by knowingly or unknowingly committing actions that result in unnecessary costs to the program. Medicaid fraud and abuse are illegal and punishable by civil and criminal laws.
Medicaid is a needs-based program. As such, applicants must provide accurate information when applying. Providing false information on an application, such as income, is fraud. Also, allowing another individual to use their Medicaid card is considered fraud. Anyone convicted of fraud may lose their benefits.
Providers often attempt to defraud the program by billing for services that are medically unnecessary. They might also submit false claims or file claims for services they have not performed. In addition, Medicaid is considered the last source of payment in the event the beneficiary has other health care coverage. If a beneficiary does not reveal they have other insurance, the program spends money on services that should be covered by another program. As such, it is considered fraud to knowingly or unknowingly not reveal all health insurance plans when applying for the program.
Individuals may report any information about Medicaid fraud committed by beneficiaries by contacting the U.S. Department of Health and Human Services Office of Inspector General. They may do so by mail or by calling the tip hotline. Anyone submitting a report may choose to remain anonymous.
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