Can You Bill a Patient with Medicaid Secondary?

Healthcare billing is complex, especially with multiple insurance plans. Understanding how these plans interact is important for proper payment. When Medicaid is a secondary payer, specific procedures and rules apply.

Coordination of Benefits with Medicaid

Coordination of Benefits (COB) prevents duplicate payments when an individual has multiple health insurance plans. It determines which plan pays first (primary) and which pays second (secondary), ensuring total payments do not exceed service costs.

Medicaid typically functions as the “payer of last resort,” paying for covered services only after all other payment sources are exhausted. These sources include private health insurance, Medicare, workers’ compensation, or other third-party liability coverage. Any other entity responsible for payment must fulfill its obligation before Medicaid contributes.

This means the primary plan must process the claim first, even if it covers only a portion or has high deductibles. Medicaid then considers payment for the remaining balance, but only for covered services and after the primary insurer’s determination. This conserves public funds by leveraging other benefits.

Primary Payer Billing Procedures

Before billing Medicaid as a secondary payer, providers must identify all patient insurance coverage. The first step is submitting the claim to the patient’s primary insurance carrier. This ensures the primary insurer processes charges according to its benefit structure and agreements.

Providers use standardized claim forms for initial submissions. These forms require comprehensive details about the patient, services, and primary insurance. Accurate submission avoids processing delays.

After submission, providers await the primary insurer’s claim adjudication. This results in an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA). These documents detail the primary insurer’s payment, amounts applied to deductibles or coinsurance, and non-covered services. This information prepares the claim for the secondary payer.

Medicaid Secondary Billing Procedures

After receiving the EOB or ERA from the primary insurer, providers can bill Medicaid as the secondary payer. This requires reviewing the primary payer’s remittance to understand payments, patient responsibility, and denials. This information is essential for accurate secondary claim submission.

The claim submitted to Medicaid must indicate a primary payer and include detailed EOB or ERA information. This includes the primary insurer’s allowed amount, paid amount, and any remaining patient responsibility like deductibles or copayments. This data ensures Medicaid coordinates benefits and determines its payment.

Medicaid processes the claim, considering primary insurer payments. It pays for covered services not fully reimbursed by the primary insurer, up to Medicaid’s maximum allowable amount. Combined payments from both insurers generally won’t exceed what Medicaid would pay as the sole payer. Providers must adhere to their state’s Medicaid program rules and submission formats for secondary claims.

Patient Financial Responsibility

Federal and state Medicaid regulations generally prohibit balance billing patients with Medicaid as a secondary payer. Providers participating in Medicaid agree to accept Medicaid’s payment, combined with primary insurer payment, as payment in full for covered services. This means providers usually cannot bill a Medicaid beneficiary for any remaining balance, even if combined payments are less than standard charges.

This prohibition protects Medicaid beneficiaries from out-of-pocket costs for covered medical care. The provider waives the difference between their usual charge and the total amount paid by the primary insurer and Medicaid. Adherence to these rules is a condition of Medicaid program participation.

However, limited circumstances allow patient financial responsibility. This includes services not covered by either the primary insurance or Medicaid. If both deem a service non-covered, a provider may bill the patient only if the patient was clearly informed and agreed in writing to pay before the service was rendered. This requires transparent communication and explicit consent.

Another area is nominal cost-sharing, like small copayments or deductibles, if allowed by state Medicaid rules. While Medicaid usually covers most cost-sharing left by a primary insurer, some state programs permit providers to collect small, state-defined copayments for certain services. If the primary insurance didn’t cover these and the state Medicaid agency allows it, the patient might be responsible for these minimal fees.

Some state Medicaid programs have a “spend-down” requirement, where individuals must incur medical expenses up to a certain amount monthly before Medicaid coverage pays. Patients are responsible for these initial expenses until their spend-down amount is met. This is a condition of eligibility, not balance billing. Patients should verify eligibility and spend-down requirements with their state Medicaid agency.

If a patient receives an incorrect bill or one violating Medicaid’s balance billing rules, they should review it against EOBs from both primary insurance and Medicaid. Discrepancies should be brought to the provider’s billing department. If unresolved, patients can contact their state Medicaid agency or a consumer protection organization for assistance. Maintaining detailed records is advisable.