Question

Details about Medicaid, private payers and reimbursement forms for CMS.

Answer 1

Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.

Medicaid in the United States is a federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and personal care services. The Health Insurance Association of America describes Medicaid as "a government insurance program for persons of all ages whose income and resources are insufficient to pay for health care. Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017. It is a means-tested program that is jointly funded by the state and federal governments and managed by the states, with each state currently having broad leeway to determine who is eligible for its implementation of the program. States are not required to participate in the program, although all have since 1982. Medicaid recipients must be U.S. citizens or qualified non-citizens and may include low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid.

The Patient Protection and Affordable Care Act (PPACA) significantly expanded both eligibility for and federal funding of Medicaid. Under the law as written, all U.S. citizens and qualified non-citizens with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. However, the Supreme Court of the United States ruled in National Federation of Independent Business v. Sebelius that states do not have to agree to this expansion in order to continue to receive previously established levels of Medicaid funding, and some states have chosen to continue with pre-ACA funding levels and eligibility standards.

Research suggests that Medicaid improves health insurance coverage, access to health care, recipients' financial security, and some health outcomes, as well as economic benefits to states and health providers.

Private payers make decisions daily about whether they will cover and pay for medical services. Each payer makes its own decisions based on its own criteria and patient population. Thus, coverage varies widely. Payment decisions are made through contracts with individual providers or provider networks, including accountable care organizations. Payment rates too vary widely among payers.