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Issue Alert - Medicaid Denial of Service Policy Changes
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| Date: |
Jan 25, 2007 |
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| Program Area: |
Medicaid |
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| Issue Summary: |
Policy on denial of service when Medicaid recipients are unable to pay Medicaid co-payments is changing again, effective February 1, 2007 |
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| Persons Affected: |
Medicaid recipients who have co-payments they are unable to pay |
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| For More Information: |
Center for Civil Justice 320 S. Washington, 2nd Floor Saginaw, MI 48607 (989) 755-3120, (800)724-7441 Fax: (989) 755-3558 E-mail: info@ccj-mi.org |
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Background |
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Federal
Medicaid law includes limits on co-payments for Medicaid-covered services,
including recipients who cannot be charged a co-payment for Medicaid-covered
services, types of services that cannot be subject to co-pays, and the amount
of the co-pays that may be required.
These are described in Issue Alert 06-04-02 http://www.mplp.org/Issues/mplpissue.2006-04-06.2409176810/view?searchterm=Medicaid%20co-payments. Federal
law also prohibits the state from allowing medical providers to deny services
to Medicaid recipients based on the recipient’s inability to pay
co-payments. (See, e.g., 42 USC 1396o(e).) In the
case of Beeker v. Olszewski, several Michigan Medicaid recipients
challenged the state’s policy allowing providers to deny services based on
co-payments for unpaid debts that in fact were Medicaid co-payments the
recipient was unable to pay, based on the federal Medicaid law. The District Court ruled in favor of the
Plaintiffs but did not certify the case as a class action and did not extend its
holding to providers other than pharmacies.
Both the Medicaid recipients who filed the case and the state appealed
the Beeker decision. The new
policy was issued as the result of a settlement of the cross-appeals, which
have now been dismissed with prejudice.
Under the
settlement agreement, the Medicaid recipients who filed the Beeker case
agreed to the changes described in the “WHAT’S HAPPENING” section of this Alert
for a period that expires on October 1, 2007.
The settlement contained other provisions, including requirements for
Medicaid Helpline assistance to recipients who are denied services based on
co-payment debts and a prohibition against amending the Medicaid State Plan
under certain co-payment provisions of the Deficit Reduction Act of 2005. Because the case was not certified as a class
action, the settlement is not legally binding on other recipients. The
outcome of the Beeker case in U.S. District Court is described in Issue
Alert 06-04-01 (available at: http://www.mplp.org/Issues/mplpissue.2006-04-04.5732227066/view?searchterm=co-payments)
and the District Court’s order in that case is available at http://www.mplp.org/Resources/mplpresource.2006-06-06.9220408665/getFile. Under policy issued by the state in response
to the District Court Order, beginning March 21, 2006, pharmacies were
prohibited from denying services to Medicaid recipients based on the
recipients’ inability to pay either current OR PAST co-payments owed for a
Medicaid-covered service. Policy for
other providers continued to state that services could be denied if the recipient
owed a bad debt) and had been given adequate notice and a reasonable
opportunity to pay the debt – even if the debt was a co-payment they were
unable to pay. The
policy changes described in this Alert and the notice that was sent to all
Michigan Medicaid recipients in January 2007 are available online by going to
http://www.michigan.gov/mdch and clicking on "Medicaid Policy Bulletins" at the
bottom of the home page. or at http://michigan.gov/documents/mdch/MSA-07-03_Bad_Debt_Bulletin_182177_7.pdf. |
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What's Happening? |
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Pharmacy policy Beginning February 1, 2007, pharmacies will be permitted
to deny services based on co-payment debts incurred on or after February 1,
2007, but only if they meet the requirements
explained in the new policy. All Medicaid
providers Beginning
February 1, 2007, there are changes in the Medicaid policy on how and when
providers may deny services to Medicaid recipients based on “co-payment debt”
for services received in the past. The
new policy explains procedures that must be followed by providers if the
providers intend to deny services to recipient based on inability to pay
Medicaid co-payment debts incurred for previously-received services. WHAT IS NOT CHANGING: The amount
of the Medicaid co-payments that may be charged, the recipients who may be
subject to co-payments, and the services for which co-payments may be charged
are NOT CHANGED. The fact
that a recipient cannot be denied services because of his or her inability to
pay the Medicaid co-payment for the service currently being requested is NOT
CHANGED. WHAT IS CHANGING: Beginning
February 1, 2007, the following changes will
be made in Medicaid co-payment collection process:
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“Appropriate
notice of the debt”, which must include documentation
of the debt “such as a billing statement, invoice, cash register receipt,
or other writing showing the co-payment amount owed” and -
Reasonable
opportunity to pay the debt.
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either
give the recipient a copy of his/her treatment record or transfer the record to
another provider, upon the recipient’s request, and -
refer
recipient’s with questions or concerns about the denial or about access to care
to the Medicaid helpline (800-642-3195) if s/he has fee-for-service Medicaid,
or to their Health Plan’s customer service number
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Has
a written policy on denial of service
based on co-pay debt that includes a. Method of furnishing notice b. Minimum length of time and terms
of payment allowed as reasonable opportunity for payment c. A statement that recipients cannot
be denied service because of inability to pay the co-payment for the currently
requested service -
Has
established procedures for maintaining
business records with the amount of
the co-pay debt, the date notice was given to the recipient, and the date(s)
and amounts of payment(s) by the recipient -
Gives notice to the recipient at
least 30 days (60 for hospitals) prior to denial of service that includes: a. Time period allowed for payment of the debt in order to avoid denial of future service b. Dollar amount of minimum payment required to avoid future denial or service c. Statement that cannot be denied
service if makes the payment in the designated amount and time period -
Gives
the notice in writing, except that verbal notice may be given if the provider: a. Publicly posts their policy on
denial of service b. Provides a copy of the policy when
verbal notice is given, or points out the posted notice and offers to provide a
copy c. Provides a copy of the policy
immediately on request Although the specific requirements summarized in section “D” above are
not imposed on physicians and dentists, they may be considered in determining
whether the notice given by the physician or dentist was appropriate and
whether the opportunity for payment was reasonable. NOTE: Remember that
Medicaid co-payments are different than Adult Medical Plan (or Plan A)
co-payments, County Plan co-payments,
Medicare co-payments (including Medicare Part D prescription co-payments),
Medicaid deductibles or spend-down amounts, and amounts owed for services that
are not covered by Medicaid. The
policy described above applies ONLY to MEDICAID CO-PAYMENTS. |
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What Should Advocates Do? |
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Advise Medicaid recipients that under federal law they cannot be
denied services because of their inability to pay Medicaid co-payments. Advise Medicaid recipients that, under state policy, providers may deny them services if they fail
to pay Medicaid co-payments for services received in the past (but after
January 31, 2007), but only if the providers give them the notice and
opportunity to pay as required by the
policy. Contact the Center for Civil Justice at (989)755-3120 if you have
questions about the legal rights of Medicaid recipients who were not named
Plaintiffs in the Beeker case or about the policy described in this
Issue Alert. Advise Medicaid recipients who are denied service in violation of
the state policy to: 1.
Call the Medicaid Helpline at (800)642-3195 to report the problem
and ask for an investigation and help getting services. |
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What Should Clients Do? |
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If you are a Medicaid recipient and are unable to pay a Medicaid
co-payment for a service you need, you should: 1. Tell your Medicaid
provider that you are unable to pay.
(You do not have to prove this, the provider must accept your word.) 2. Call the Medicaid
Helpline at (800) 642-3195 if you are denied a service because you cannot pay the
Medicaid co-payment for the service that is being denied. Report the problem and ask the Helpline to
help you get the medical services you need. 3. Call the Center for
Civil Justice at (800) 724-7441 if the Helpline does not solve the
problem. If you are a Medicaid recipient and are being denied service
because you are unable to pay a Medicaid co-payment for a service you received
in the past: 1.
If the co-payment is owed for a service you received before
February 1, 2007, call the Medicaid Helpline at (800)642-3195 to report the
problem and ask for help because the provider should not deny you service based
on bills owed before this date. 2.
If the provider did not give you appropriate notice of the bill
and a reasonable opportunity to pay the co-payment, call the Medicaid Helpline
at (800)642-3195 to report the problem and ask for help. 3.
If the Medicaid Helpline does not solve the problem, call the
Center for Civil Justice at (800)724-7441. 4.
If the provider gave you notice and an opportunity to pay but you
still are unable to pay and you still cannot get medical care or services you
need, call the Center for Civil Justice at (800)724-7441. |
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Finding Help |
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Most legal aid and legal services offices handle these types of cases, and they do not charge a fee.
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