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Medicaid / Medicaid FAQs

Medicaid FAQs

Medicare and Medicaid are two separate, state and federal-run programs to provide health coverage people falling under different criteria and eligibility. Medicare intends for those who are 65 years or more and have a disability, with no restrictions to income limits. Medicaid is for those with very low income, however, there are restrictions to income and asset that varies according to the 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 to home care agency 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

The 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 genuinely require long-term care. Once approved, the patient can select the Medicaid program of choice. In the second step, the patient is again evaluated by another nurse to complete the enrollment process.

Yes, it is covered. However, it is not so easy to obtain 24 hour home care covered by Medicaid. It all depends if 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 of Medicaid. This is because home care providers are able to 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 an 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 visitsM
  • 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, he or she can still qualify for Medicaid coverage. The individual will be assessed for the need of help required daily routine activities like bathing, dressing, and toileting.

Yes, Medicaid is available only to those that meet the income and asset guidelines as defined by the state. For every state, the guidelines and limits are different.

The application process for availing Medicaid is not complex and 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 the states, Medicaid pays for home care services including In-home health care, Personal care services such as help bathing, eating, and moving.

The Centers for Medicare and Medicaid Services (CMS) implement, monitor, and support Medicare nationwide, thus it follows standard billing requirements across the country.
The states administer and control Medicaid, thus home care service providers are required to meet all state-specific Medicaid billing requirements for each state they plan to bill in.
Home care businesses operating in multiple states know that most states make use of the same electronic format for Medicaid claim submission. However, the process of claim transmission may vary from state-to-state.

Medicaid programs are funded by the state and federal government and provide health coverage for seniors, pregnant women, parents, children, disabled, and caregivers. Anyone outside these with low-income is not covered under Medicaid.

Because of the number of available Medicaid programs, a number of states have renamed 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 Medicaid
  • TennCare is Tennessee Medicaid
  • Healthy Connections is South Carolina Medicaid
  • The Oregon Health Plan is Oregon Medicaid
  • SoonerCare is Oklahoma Medicaid
  • Centennial Care is New Mexico Medicaid
  • MO HealthNet is Missouri Medicaid
  • MaineCare is Maine Medicaid
  • Healthy Louisiana is Louisiana Medicaid
  • KanCare is Kansas Medicaid
  • IA Health Link is Iowa Medicaid
  • MedQUEST is Hawaii Medicaid
  • Health First Colorado is Colorado Medicaid
  • Husky Health is Connecticut Medicaid
  • Medi-Cal is California Medicaid
  • While some of the remaining states kept it simple and did not change to any state-specific name, there are few states where Medicaid is referred as Medical Assistance.

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

HCBS or commonly known as Home and community based services are meant for Medicaid recipients to receive care services in their own home or community instead of staying in medical facilities, at institutions or any 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/or mental illnesses.

Medicaid is not accepted by all the home care businesses providing care services. The state’s Medicaid agency maintains a directory of all the service providers that accept Medicaid. Since a number of Medicaid programs allow having a home care aide of choice, one can hire a caregiver as per their preference.

Only if the person is eligible and the services provided are covered by Medicaid, the unpaid medical bills and care invoices will 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, different states may have different hourly rates ranging from $15.25 to $28.

Different states have different application process and criteria to enroll Medicaid providers. After registering, providers also need to 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:

  • Manual submission of Medicaid claims generated on paper forms.
  • By utilizing the services of a clearing house as an intermediary whose responsibilities include taking paper forms for Medicaid claims and verifying them for information accuracy before submitting to the payer in lieu of certain fees.
  • Electronic Medicaid billing by using an electronic home care billing software that manages all the billing data automatically, generate 837p or 837i forms, review and submit 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) in order to get accepted for the processing and reimbursement of the claims. In case, if the agency is providing care services to a client who has other insurance, an exception is allowed past the 365-day limit.

There are a number of options for home care businesses that allows them to bill Medicaid for their clients and seek reimbursement from the state agency. If a care service provider is planning 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 a home care business software, talk to your vendor to upgrade the billing module for Medicaid. It is always better to go with a new advanced software embedded with intelligent features and capabilities that helps businesses to grow and simplify important tasks such as billing, scheduling, tracking, payroll, and more.

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

Home care businesses can seek Medicaid reimbursement only when they are certified as an HHA (Home Health Agency) in the Medicare program. Each state has a different set of regulations regarding the certification, except for Idaho, South Dakota, and Vermont. The states have a checklist for HHAs to help them determine what certifications and licenses are required to provide care services. Moreover, non-medical private-duty home care agencies are even exempted from certifications in some states. Home care startups can find certification requirements from their state’s Department of Human Services or Bureau of Licensing and Certification.

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 submit error-free claims for processing, giving an edge to home care businesses with substantial reduction in incomplete claims, missed entries, invalid diagnosis codes, incorrect rates, and duplicate claim-related denials. CareSmartz360 is integrated with advanced bookkeeping algorithm to handle all the accounts and every penny without any hassle so that the agencies always know which claims are paid and which claims need follow up.

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Medicaid with CareSmartz360

Home care businesses require advanced solutions to integrate Medicaid into their services, and Caresmartz has been doing that across the states for home care agencies, private-duty care providers, and home care franchisors for several years. CareSmartz360 is a complete software solution to manage a home care business, and it 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.
  • Built-In feature to submit claims electronically.
  • Quickly create, review, approve and submit claims in paper invoice or 837P, 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.
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