Medicaid

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Medicare and Medicaid are separate, state and federal-run programs that provide health coverage for people falling under different criteria and eligibility. Medicare is intended for those 65 years or older with a disability, with no restrictions to income limits. Medicaid is for those with very low income. Eligibility for Medicaid varies from state to state and is means-tested, considering income and assets.

In summary, Medicare is age and disability-based, while Medicaid is income and asset-based, with eligibility rules varying by state.

Services such as:

• Physical therapy
• Speech-language pathology
• Continued occupational therapy
• Intermittent skilled nursing care

While providing personal care services to clients, Medicaid will pay home care agencies for:

• Home care services (i.e., A home health care aide) on a long-term basis
• Adult daycare program
• Transportation to medical appointments
• Prescriptions covered via Medicare Part D, Medicaid will pay the monthly Part D premium

Enrollment in an MLTC Plan is a two-step process – One in which the patient is assessed by a nurse from the Conflict-Free Evaluation and Enrollment Center (CFEEC). This is done to verify if the person enrolling requires long-term care. Once approved, the patient can select the Medicaid program of choice. In the second step, another nurse again evaluates the patient to complete the enrollment process.

Yes, it is covered. However, obtaining 24-hour home care covered by Medicaid is not so easy. It all depends on whether you really need such care after a clinical assessment. A home care agency in your local area can guide you in this.

The health coverage is granted at the beginning of the month when someone is approved for Medicaid. This is because home care providers can bill for services rendered in the month the application was submitted. This is known as “Medicaid pending” home care.

An individual willing to receive Medicaid pending home care from the potential care service provider can go for this. However, the service provider will ask to see/submit a copy of the application that was submitted. Those with higher income experience a bigger challenge to get approved for Medicaid pending services. An ideal candidate to receive this service depends upon the serviceability policies of an HHA.

Generally, there is no time constraint while availing home care services from active Medicaid or Medicaid pending. As a common rule, it is usually 8 hours a day or even less.

Yes, Medicaid can pay a family member for the care services if you meet the medical and financial criteria. Medicaid home care benefits also depend on the Medicaid program in which you are enrolled. The services included under Medicaid and are paid to family members are:

• In-home health care
• Adult daycare
• Skilled nursing care
• Respite care
• Basic cleaning and laundry tasks
• Simple meal preparation or food delivery
• Transportation to and from medical visits
• Personal care services, like dressing and bathing
• Medicaid equipment (wheelchairs and walkers)
• Making modifications for a wheelchair ramp or widening a doorway

When someone needs a medical facility or nursing home level of care or maybe less care, they can still qualify for Medicaid coverage. The individual will be assessed for the need for help required daily routine activities like bathing, dressing, and toileting.

Yes, Medicaid is available only to those who meet the state’s income and asset guidelines. For every state, the guidelines and limits are different.

The application process for availing Medicaid is not complex. Anyone can apply for the available Medicaid programs by visiting the respective state’s Medicaid agency in person or online. However, the application approval may take some time, and if the eligibility guidelines are not met specifically, there are chances of denial.

Medicaid is for those who are categorized as low-income individuals with predefined income limits and assets according to different states. In almost all states, Medicaid pays for home care services (including In-home health care) and Personal care services (such as help with bathing, eating, and moving).

The Centers for Medicare and Medicaid Services (CMS) implement, monitor, and support Medicare on a national level, which means that standard billing requirements are followed throughout the country. However, the states administer and control Medicaid, which means that home care service providers are required to comply with state-specific Medicaid billing requirements for each state they plan to bill in. For home care businesses operating in multiple states, it is important to note that most states use the same electronic format for Medicaid claim submission. However, the process of claim transmission may vary from state to state.

The state and federal governments fund Medicaid programs. As such, they provide health coverage for seniors, pregnant women, parents, children, disabled, and caregivers alike. Anyone outside these demographics, even those classified as low-income, is not covered under Medicaid.

Several states have renamed Medicaid programs because of the number of available Medicaid programs. Such as:

• MassHealth is Massachusetts Medicaid
• Equality Care is Wyoming Medicaid
• Health Care Cost Containment System is Arizona Medicaid
• Statewide Medicaid Managed Care is West Virginia Medicaid
• Green Mountain Care is Vermont’s Medicaid
• TennCare is Tennessee Medicaid
• Healthy Connections is South Carolina Medicaid
• The Oregon Health Plan is Oregon Medicaid
• SoonerCare is Oklahoma’s Medicaid
• Centennial Care is New Mexico’s Medicaid
• MO HealthNet is Missouri Medicaid
• MaineCare is Maine Medicaid
• Healthy Louisiana is Louisiana’s Medicaid
• KanCare is Kansas Medicaid
• IA Health Link is Iowa Medicaid
• MedQUEST is Hawaii’s Medicaid
• Health First Colorado is Colorado’s Medicaid
• Husky Health is Connecticut’s Medicaid
• Medi-Cal is California’s Medicaid

While some remaining states kept it simple and did not change to any state-specific name, there are few states where Medicaid is referred to as Medical Assistance.

Home care services rendered to someone can be paid by the regular state Medicaid program, Home-Based and Community-Based Services (HCBS) Medicaid waivers, or even Section 1115 demonstration waivers.

HCBS, commonly known as Home Community-Based Services, is meant for Medicaid recipients to receive care services in their homes or communities instead of in medical facilities, institutions, or other isolated settings. It is designed to serve people who need necessary medical care and help with day-to-day tasks, individuals with intellectual or developmental disabilities, physical disabilities, and mental illnesses.

Only if the person is eligible and Medicaid covers the services provided will the unpaid medical bills and care invoices be reimbursed through Medicaid.

Being a care provider, you can bill out-of-state Medicaid. However, Federal law prohibits billing Medicaid patients from other states.

$21 is the average hourly fee. However, states may have different hourly rates ranging from $15.25 to $28.

Different states have different application processes and criteria to enroll Medicaid providers. After registering, providers must also register with the intended state Medicaid program for which they plan to bill and seek reimbursement.

Home care agencies can bill Medicaid in the following ways:

• Agencies can opt for manual submission of Medicaid claims generated on paper forms.
• Another approach involves leveraging the services of a clearing house. Acting as an intermediary, the clearing house is responsible for receiving paper forms for Medicaid claims, verifying them for accuracy, and then submitting them to the payer. However, it’s important to note that this method often incurs certain fees.
• Electronic Medicaid billing uses an electronic home care billing software that automatically manages all the billing data, generates 837p or 837i forms, and reviews and submits the claim for payment. CareSmartz360 is an example of a home care Medicaid billing software.

Starting from the first day of service, an agency has to submit Medicaid claims within a year (365 days) to get accepted for the processing and reimbursement of the claims. If the agency provides care services to a client with other insurance, an exception is allowed past the 365-day limit.

There are several options for home care businesses that allow them to bill Medicaid for their clients and seek reimbursement from the state agency. If a care service provider plans to implement a software solution to manage every aspect of his business, ask if the software allows creating, reviewing, and submitting Medicaid electronically. For existing businesses utilizing home care business software, talk to your vendor to upgrade the billing module for Medicaid. It is always better to use new advanced software embedded with intelligent features and capabilities to help businesses grow and simplify important tasks such as billing, scheduling, tracking, payroll, etc.

Yes. Nowadays, most home care software comes with advanced features that can be customized per the needs. It can generate, review, and submit Medicaid bills to the state agency for reimbursement.

CareSmartz360 is a complete software solution to manage home care business and supports all Medicaid payers, allowing businesses to focus on other operations and processes.

• Effective and comprehensive management of the revenue cycle
• Allows agencies to fulfill billing requirements for Medicaid, Medicare, Insurance, and Private Pay
• In-built feature to submit claims electronically
• Quickly create, review, approve, and submit claims in 837p or 837i format
• Helps in generating error-free claims to save time and efforts
• Identify and manage accounts and claims that are overdue
• Robust reporting to evaluate financial performance

The Medicaid billing module of CareSmartz360 creates and submits error-free claims for processing, giving an edge to home care businesses with a substantial reduction in incomplete claims, missed entries, invalid diagnosis codes, incorrect rates, and duplicate claim-related denials. CareSmartz360 is integrated with advanced bookkeeping algorithms to handle all the accounts (and every penny) hassle-free. This helps agencies always know which claims are paid and which need follow-up.