New Medicaid and CHIP Regs Offer Mixed Bag for Healthcare Providers

Finally, someone has explained what the final rule by CMS covering the Patient Protection and Affordable Care Act’s provisions regarding Medicaid and Children’s Health Insurance Program will mean to healthcare providers.

The new rule, more than 600 pages long, is daunting reading. Most of the regulations are aimed at U.S. citizens, health insurance exchange operators, and local, state, and federal governments. But many of the new regulations affect healthcare providers, and thanks to Timothy Jost, writing in the Health Affairs blog, we have some idea what those impacts will be.

There are two areas in particular where healthcare providers must have some awareness: presumptive eligibility and Medicaid cost sharing.

Presumptive eligibility

“Current law permits states to allow ‘qualified entities’ to make presumptive eligibility decisions for children,” writes Jost.  ”The regulation allows states to extend presumptive eligibility to cover pregnant women, limiting such determinations to one per pregnancy.  The final rule also permits states that allow presumptive eligibility determinations for children and pregnant women to allow qualified entities to make presumptive eligibility determinations for individuals in other eligibility categories.”

The new regulations extend to hospitals, which now are allowed to immediately enroll patients into Medicaid if they are found to be qualified.  ”Hospitals must be allowed to make presumptive eligibility decisions for Medicaid categories where eligibility is income-based, and may be authorized to make eligibility determinations based on other grounds,” he writes.

Before any hospital assumes this responsibility, it must notify the Medicaid agency in its respective state that it intends to do so and will conform to state standards. “States may not, however, recoup funds paid to a hospital pursuant to an erroneous presumptive eligibility determination,” according to Jost.

Medicaid cost sharing 

The new regs permit, if not encourage, cost sharing for Medicaid patients, because  ”Congress has concluded that cost sharing and premiums can be affordable for some Medicaid populations, particularly those with higher incomes, and states have demanded the ability to impose it to discourage moral hazard,” writes Jost.  ”The regulation also permits targeted cost sharing specifically to discourage inappropriate use of emergency rooms and to encourage the use of less expensive, preferred drugs.”

The new regs have put the burden of cost sharing on providers, and

“In situations where cost sharing is permitted, the state agency must reduce provider payments to reflect cost sharing the provider should have collected, regardless of whether it is actually collected,” writes Jost. ”Providers must accept payments from Medicaid in this circumstance as payment in full.”

Providers will be allowed to collect cost-sharing fees, but will not be able to deny services to those unable to pay those fees “except for non-emergency services provided in an emergency department to a beneficiary who is not in an excepted group and who has an income above 100 percent of the poverty level,” he writes.