In today’s health care system, many patients struggle to get the health care that they need, while hospitals struggle to get paid for the services that they provide. To fill this gap, there are two systems that can work hand-in-hand to care for both the patients and the health care providers—Medicaid and Healthcare Advocates.
Determining Patient Eligibility for Medicaid
Medicaid was created in 1955 to cover health care for Americans who are unable to work. States don’t have to participate, though they all do. Participating states must meet parameters set by the Center for Medicare and Medicaid Services to get federal funding, but they also have a lot of control over eligibility and covered health care services. Additionally, the qualifications to be eligible for coverage vary from state to state. Some states have recently adopted a Medicaid expansion to cover all people below a certain income, but this expansion has not yet passed nationwide.
When the Affordable Care Act passed in 2013, it established a new methodology for determining income eligibility for Medicaid, which is based on Modified Adjusted Gross Income (MAGI), or the income before taxable deductions. Those deductions include non-taxable Social Security benefits, individual retirement contributions and tax-exempt interest. This MAGI-based methodology does not allow for income disregards that vary by state or by eligibility group, and does not allow for an asset or resource test.
Coordination of Benefits
Coordination of Benefits (COB) refers to the activities involved in determining Medicaid benefits when an enrollee has coverage through an individual, entity, insurance or program that is liable to pay for health care services. Individuals who are eligible for Medicaid assign their rights to third party payments to the State Medicaid Agency.
Examples of third parties which may be liable to pay for services:
- Group health plans
- Self-insured plans
- Managed care organizations
- Pharmacy benefit managers
- Medicare
- Court-ordered health coverage
- Settlements from a liability insurer
- Workers’ compensation
- Long-term care insurance
- Other state or Federal coverage programs (unless specifically excluded by law)
The COB process ensures claims are paid correctly by identifying the health benefits available to a Medicare beneficiary, coordinating the payment process, and ensuring that the primary payer, whether Medicare or other insurance, pays first. It also shares Medicare eligibility data with other payers and transmits Medicare-paid claims to supplemental insurers for secondary payment and ensures that the amount paid by plans in dual coverage situations does not exceed 100% of the total claim, to avoid duplicate payments.
Charity Care as Another Healthcare Option
Charity Care is another health care option available to low income patients. There are several factors that can contribute to Charity Care eligibility:
- Individual or family income, which may take into account family size, geographic area, and other pertinent factors. Individual or family income generally is not the exclusive criterion for determining the appropriate amount of charity care.
- Individual or family net worth, which considers liquid and non liquid assets owned, less liabilities and claims against assets. It should be noted that when from the patient, it is useful to clarify whether this information will be used solely to determine eligibility or whether the assets would be considered as a possible source of payment.
- Employment status criteria should consider the likelihood of future earnings sufficient to meet the health care-related obligation within a reasonable period of time.
- Other financial obligations, for example, living expenses and other items of a reasonable and necessary nature.
- Amount and frequency of health care bills, or the potential for medical indigence (sometimes referred to as medical hardship), must be considered in relation to all the other factors outlined above. The history of service and the need for future service by the institution or other providers may be considered. In these cases, a separate determination of the amount of charity care for which a patient is eligible is made on each occasion of service, or regular confirmation of eligibility is made during extended programs of service.
- Other financial resources available to the patient, such as Medicaid and other public assistance programs, will affect the determination of the appropriate amount of charity care.
Understanding State-by-State Requirements
While Medicaid is available in every state, each state has its own guidelines that must be followed. States jointly fund and run their programs, which means Medicaid eligibility will vary depending upon where a patient lives. However, requirements are broadly based on income, disability, pregnancy, age, household size and household role. While eligibility requirements change on a consistent basis (most recently with November 2018 elections), we have compiled a list of requirements for each state. These guidelines cover incomes, ages, disability status and more. All of these guidelines can be found in our free State by State Medicaid Guide.
Generally, if a patient makes less than 100% to 200% of the federal poverty line (FPL) and is pregnant, elderly, disabled, parent/caretaker, or a child, there is likely a Medicaid option for them.
Choosing an Eligibility Advocate
There are many services that can help a hospital or health care provider navigate the complicated system of patient eligibility. These health care eligibility advocates are trained and able to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms.
When choosing an eligibility advocate, there are several criteria that should be considered:
- Capture rates- How effective is the advocate? Ask about their capture rate. This percentage refers to the quantity of patients who receive coverage when working with a advocate. The DECO standard is 94%.
- Field visits- Does your advocate work on site? Advocates who work directly with the patients have a much higher success rate than those who work off-site.
- Cycle times- How long does it take for payment to be received? An advocate should be able to decrease your cycle time while increasing revenue.
- Training- Does your advocate supply training for your staff? Advocates should act as an extension to your service, not a replacement for your current staff.
At DECO, we focus on streamlining your existing revenue cycle management (RCM) system, as well as advocating for your patients to receive health care coverage. Our talented, multilingual staff, is able to offer patient-centric eligibility services that will ultimately benefit your hospital’s financial health. Our 94% capture rate means that you get paid for the services you provide, and don’t have to use valuable resources to make it happen. To learn more about our services, contact us today.
