Working with Medicaid
According to Valerius, Bayes, Newby, Seggern (2008), the Medicaid program is to help pay for health care needs of individuals and their families and these families would have low incomes and few resources. People who apply for Medicaid must meet certain federal requirements, but they must also meet additional requirements in the state where they live (Valerius, Bayes, Newby, and Seggern.2008, p. 374). The state determines the eligibility by examining an individual’s income, current assets, and assets that the individual transferred to another person’s name. Different states have different plans, which include fee-for-service and managed care plans (Valerius, Bayes, Newby, and Seggern. 2008, p. 385). Medicaid has a network of physicians for the individual to make a choice. The individual chooses a primary care physician (PCP) and if the individual needs to see a specialist, then the physician has to provide a referral, or Medicaid will not pay for the service (Valerius, Bayes, Newby, and Seggern. 2008, p. 385). Procedures that Medicaid will not pay for are; procedures not medically necessary, such as experimental, investigational, and cosmetic procedures (Valerius, Bayes, Newby, and Seggern. 2008, p.391).
If the individual wants to see a specialist without a referral from the (PCP), then the individual is directly from the specialist he or she sees. The only time a provider can bill the patient directly is when the physician informs the patient, in advance. The physician explains to the patient that the procedure is not covered; the facility has established a written policy for non-covered services to all patients, and the patient simply consultated before the charges, and having a signed document from the patient (Valerius, Bayes, Newby, and Seggern. 2008, p.386).
The federal government and the stated jointly fund the Medicaid program. The government pays the states for a specified percentage of program expenditures. States have the...