Department of Health Care Policy and Financing statement regarding billing of Medicaid members

Monday, December 29, 2014 03:45 PM

Medicaid expansion in Colorado means that thousands of Coloradans now have health insurance, some for the first time. While this is positive overall, it has also created pressure on the Medicaid provider network. Medicaid members may sometimes seek services from non-Medicaid providers, who may not know or understand Colorado law regarding billing Medicaid members.

We are receiving numerous questions regarding the ability of health care providers to bill Medicaid members for co-insurance, deductibles, or full payment for services. It is important that all health care providers know that Medicaid members cannot be billed for any service covered by Medicaid.

Colorado law (C.R.S. 25.5-4-301(II)), states that no Medicaid member shall be liable for the cost, or the cost remaining after payment by Medicaid, Medicare, or a private insurer, of medical benefits authorized under Title XIX of the Social Security Act. This law applies whether or not Medicaid has reimbursed the provider, whether claims are rejected or denied by Medicaid due to provider error, and whether or not the provider is enrolled in the Colorado Medical Assistance Program. This law applies even if a Medicaid member agrees to pay for part or all of a covered service.

Payment may be collected from or billed to a Medicaid member only if the specific service rendered is not covered by Medicaid. In this situation, the Department requires that providers obtain a statement prior to service, signed by the Medicaid member, acknowledging that the specific service is not a Medicaid-covered benefit and agreeing to pay.

The Department encourages providers to consider enrolling with Medicaid to ensure reimbursement for services provided to Medicaid members. Medicaid enrollment also gives providers easy access to checking a patient’s eligibility for Medicaid or CHP+ prior to providing services.

Enrolling in Medicaid does not mean that a provider must accept all Medicaid members who request services. Medicaid providers have full control of the number of Medicaid patients they see. Accepting both commercial insurance and Medicaid also means providers can serve families with mixed health insurance coverage, and can continue to serve patients when their circumstances change and along with them, their health insurance. Medicaid and your communities need you – please consider enrolling today.

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For questions related to the proper billing of Medicaid-covered claims, please call the Fiscal Agent, Xerox, at 1-800-237-0757. For more information about the benefits of enrolling with Medicaid, please contact Marceil Case, Provider Relations Manager, marceil.case@state.co.us.