New York Medicaid Program Prohibits Billing Beneficiaries

When a provider participates in the New York State Medicaid Program, a provider agrees to accept payment as payment in full for the provided services. The same applies to providers who accept Medicaid Managed Care or Family Health Plus (FHPlus) plans.

That means that demanding or collecting any reimbursements in addition to claims made under the Medicaid program, except where permitted by law, is prohibited.

Providers should be aware that if they participate in Medicaid fee-for-service but do not participate in the enrollee’s Medicaid Managed Care Plan, they may not bill Medicaid fee-for-service for any services that are included in the Managed Care Plan, with the exception of family planning services. Neither may such providers bill the enrollee for services that are covered by the enrollee’s Medicaid Managed Care contract unless there is a prior agreement with the enrollee that he/she is being seen as a private patient.

Agreements between a provider and patient that attempt to circumvent the rules of the Medicaid programs are also disallowed. For example, a private pay agreement with an enrollee to accept a Medicaid fee for a particular covered service in order to provide a different upgraded service not covered by Medicaid, bill Medicaid for the covered service, and agree to charge the enrollee only the difference in fee between two services, is expressly prohibited.

A provider and a Medicaid recipient, including those with Medicaid Managed Care or FHPlus plans, may, however, enter into a private pay agreement under certain circumstances. According to Medicaid:

A provider may charge a Medicaid enrollee, including a Medicaid enrollee enrolled in a Managed Care Plan, ONLY when both parties have agreed PRIOR to the rendering of the service that the enrollee is being seen as a private-pay patient.  This must be a mutual and voluntary agreement.  It is suggested that the provider maintain the patient’s signed consent to be treated as private pay in the patient record. (New York State Medicaid Program, Information for All Providers, General Policy, V-2011-2) (emphasis in the original).

If the services are covered by an enrollee’s Managed Care Plan, then the provider must inform him or her that the services may be obtained at no cost from a provider that participates in the enrollee’s Managed Care Plan.

Providers are also advised by Medicaid that “[d]ue to the requirement that PRIOR agreement be made for reimbursement, Medicaid beneficiaries may never be charged for services rendered in an Emergency Room (except applicable Medicaid co-payments).”

Providers are prohibited from referring Medicaid beneficiaries to a collection agency for collection of unpaid medical bills, except for applicable Medicaid co-payments, which may be collected by any legal means.

Providers are advised by Medicaid to verify patients’ eligibility each time services are rendered. “If the provider does not verify the eligibility and extent of coverage of each enrollee each time services are requested, then the provider will risk the possibility of nonreimbursement for services provided as the State cannot compensate a provider for a service rendered to an ineligible person.  Eligibility information for the enrollee must be determined via the MEVS.”

For more information, see New York State Medicaid Program, Information for All Providers, General Policy, V-2011-2; New York State Medicaid Update, Feb. 2011.

If you have questions about the New York State Medicaid Program or need other legal assistance, please contact us.