How Does Medicaid Work?
Eligibility for Medicaid is determined by the Division
of Public Assistance according to federal and state rules. The
case worker will look at age, income, assets, disability status, and
other factors to determine what eligibility category may work. (
Use This Linkfor program and services applications.) Once
determined eligible, the individual will be assigned a unique identification
number and issued a Medicaid coupon, which contains information on removable
most part, recipients are able to choose their own health care provider,
but before Medicaid will pay the medical bill, the provider must be
enrolled with the Medicaid program. When services are provided, the
enrolled provider removes one of the labels and sticks it on a special
claim form. Some providers are also able to submit claims electronically.
All prescription drug claims are submitted electronically. Before
Medicaid reimburses the provider, a claim review is done to make sure
the claim fits within acceptable medical and fiscal guidelines.
rates for physicians and other private practice providers are established
according to a methodology that assigns a relative value to the service
provided. Hospital and nursing home rates are established by a special
rate setting commission. Except for established recipient cost sharing
amounts, providers must agree to accept the Medicaid rate as full
reimbursement and not require the recipient to pay more.