“Medicaid Won’t Cover That” (and Other Misconceptions)

Medicaid is a complex area of law, and misconceptions about it abound. Lawyers representing children and youth can strengthen their legal representation by having a basic understanding of Medicaid rules and regulations so that they can advocate for services and coverage for their clients. 

1. “All Medicaid programs and plans are the same.”

Medicaid programs are primarily administered by state governments, and the federal government oversees these programs and sets minimum requirements and standards. Medicaid programs hence vary greatly from state to state, but these programs must adhere to certain federal statutes and regulations. Federal Medicaid regulations can be found at 42 U.S.C. §1396 et seq.

Furthermore, the Medicaid programs administered by state governments may offer a variety of insurance plans within a state. Some Medicaid recipients may be required to enroll in a Medicaid plan through an insurance company, whereas others may have Medicaid directly from the government, called fee-for-service Medicaid. If you need information about your client’s plan, call the information line with your client or with a release from your client (signed by your client’s parent or guardian if the client is a minor). You may need to have the client’s Medicaid card (or a copy of it), or at least the Medicaid ID number, ready for the call.

2. “The Medicaid call center said. . . .”

If you call your state’s Medicaid agency customer service, be sure to have your client’s Medicaid ID number. You will likely either need to have the client (or the client’s parent or guardian if your client is a minor) on the phone with you to give consent to share information or submit a signed release of information form to the Medicaid agency. Also note that customer service agents may not be well versed in some areas of Medicaid law, so you should double-check any advice they offer. If you are unable to locate attorneys with expertise in Medicaid in your state, the National Health Law Program is a national organization with expertise in Medicaid.

3. “There’s nothing you can do if Medicaid denies a service.”

Federal law requires that Medicaid agencies and Medicaid insurance plans provide an opportunity to appeal adverse actions. Appeal deadlines vary among the states, but the minimum deadline set by the Centers for Medicare and Medicaid Services is 20 days. Decisions made by Medicaid insurance plans (which most Medicaid members are enrolled in) may be subject to different appeal deadline requirements than the Medicaid agency requirements, and generally the first level of appeal for plans is an internal appeal rather than a fair hearing.

Federal law requires that Medicaid agencies and Medicaid insurance plans provide written notice of adverse actions (terminations, suspensions, or reductions in benefits or services) to members. The notice must be sent to the Medicaid member or applicant at least 10 days (which may be greater in some states) prior to the intended action. Pay close attention to these notices and appeal deadlines. If you do not receive a written notice, the appeal deadline may be more generous (which may be calculated from the date of adverse action). Check your state’s rules. Even if you believe that the adverse action might be resolved with a phone call, or you’re not yet sure about the merit of the appeal, you should ensure that your client preserves his or her right to appeal by submitting a timely appeal request. Generally, one can request that benefits or services continue through the appeal process if the appeal is submitted within 10 days of receiving written notice of the adverse action—though some states may require repayment if the member loses his or her appeal.

4. “Medicaid won’t cover that.”

Sometimes healthcare providers assume that Medicaid will not cover a service without actually submitting a prior authorization request for the service. You need a written denial to appeal. Ask the provider to submit a prior authorization request for a service the provider says won’t be covered so that you can appeal it if it is denied. Check your Medicaid agency’s prior authorization requirements to determine whether a particular service denial may have a meritorious appeal.

5. “There’s nothing you can do if Medicaid says you are not eligible.”

Federal law requires that Medicaid agencies and Medicaid insurance plans provide a written notice of the denial of eligibility, as well as an opportunity to appeal a denial of eligibility. Note the appeal deadlines set by the state Medicaid program. Also note that in some states, children in foster care or other Title IV-E programs are automatically enrolled into Medicaid, but not in other states. States have the option (but are not required) to provide automatic coverage to children in state adoption programs not covered under Title IV-E.

6. “Medicaid never lets you go out of network.”

In most states, Medicaid enrollees must be enrolled in a managed care plan if Medicaid is their primary insurance. Enrollees must generally stay within their plan’s provider network—unless the plan grants permission to see a provider out-of-network. An enrollee can request an out-of-network waiver (sometimes called a single case agreement) if there is no available in-network provider that can meet the enrollee’s specific health needs. Medicaid enrollees may also be able to change plans outside of open enrollment if they move to a new geographic area or for other specific reasons (check your state’s policy).

7. “If you are not eligible for Medicaid, then your child is not eligible for Medicaid.”

Adults and minors are subject to different eligibility rules for Medicaid, so a parent’s ineligibility does not necessarily preclude the child’s eligibility. Families should also plan for when their child enters adulthood. Rules can differ between adults and minors in terms of financial eligibility, immigration eligibility, and more.

8. “The doctor said I’m not eligible.”

Some healthcare providers incorrectly advise clients about Medicaid eligibility or what Medicaid will or won’t cover. Always check your state’s Medicaid regulations and policy documents.

9. “Incarcerated youth are not eligible for Medicaid coverage.”

Some states allow eligible juveniles to remain enrolled in Medicaid while incarcerated if the disposition of charges is pending. For those who lose their Medicaid or other health insurance while incarcerated, insurance enrollment should be part of the release planning process.

10. “There is nothing I can do about my medical debt from when I was uninsured.”

In the vast majority of states, Medicaid applicants can qualify for up to three months of coverage retroactive from the date of application if the applicant was eligible for Medicaid during that time period. However, it generally needs to be affirmatively requested; it is not applied automatically. Retroactive coverage can be an important tool in resolving medical debt.