Medicaid

Medicaid in United States

Plain-English Law

Medicaid as defined by Nolo’s Encyclopedia of Everyday Law (p. 437-455): A federal program that provides health insurance for financially needy people. The program is administered by each state.

Medicare and Medicaid

The Medicare and Medicaid plans are programs of medical care for the aged and for the needy, respectively, in the United States. The Medicare and Medicaid programs are under the direction of the United States Department of Health and Human Services.

Introduction to Medicaid

Medicaid is a federal-state program, usually operated by state welfare or health departments, within the guidelines issued by the Centers for Medicare & Medicaid Services. Medicaid furnishes at least five basic services to needy persons: inpatient hospital care, outpatient hospital care, physicians’ services, skilled nursing-home services for adults, and laboratory and X-ray services. The people who are eligible include families and certain children who qualify for public assistance and may include aged, blind, and disabled adults who are eligible for the Supplemental Security Income program of the Social Security Administration. States may also include persons and families termed “medically needy” who meet eligibility requirements except those for financial assistance. Each state decides who is eligible for Medicaid benefits and what services shall be included. Some of the benefits frequently provided are dental care; ambulance services; and the cost of prescription drugs, eyeglasses, and hearing aids. In determining eligibility for the program, a state may not hold adult children responsible for medical expenses of their parents.

All the states, the District of Columbia, Guam, Puerto Rico, and the Virgin Islands operate Medicaid plans. In 2002 some 39.9 million people received Medicaid health-care support. Under the 2003 legislation that revised Medicare, Medicaid recipients were brought under Medicare’s prescription drug program. As low-income recipients, Medicaid patients pay $1 for each generic drug prescription and $3 for each brand-name prescription.” (1)

Medicaid and Medicare Legal Materials

Most of the relevant legal materials are compiled in CCH Medicare and Medicaid Guide, available as a multi-volume looseleaf and as an online subscription throughIntelliconnect. Lots of information is posted by the Centers for Medicare & Medicaid Services, formerly the Health Care Financing Association (HCFA). Medicare information for consumers is posted on Medicare.gov.

Advisory Opinions:

  1. CMS Advisory Opinions provide guidance for doctors referring patients to an affiliated facility (e.g. a surgicenter). The CMS Advisory Opinions (AOs) provides additional information and the Opinions in PDF format. They are also available in the CCH Medicare and Medicaid Guide (with the “Reports and Other Documents” on Intelliconnect); you can set up a customized Tracker on Intelliconnect to catch them as they come out.
  2. OIG Advisory Opinions concern anti-kickback laws and other “fraud and abuse” issues. The HHS OIG’s office provides more information and the Opinions on their Advisory Opinions (AOs) page. They are also available in the CCH Medicare and Medicaid Guide (with the “Reports and Other Documents” on Intelliconnect).

Drug Utilization Review Reports: Each state files a Medicaid Drug Utilization Review (DUR) report with CMS each year. CMS posts the Reports here starting in either 2010 or 2011. You may also be able to find the DUR reports on the website for the relevant state agency.

Fraud: Useful treatises discussing Medicare and Medicaid fraud include Medicare and Medicaid Fraud and Abuse (Thomson/West) and Prosecuting and Defending Health Care Fraud Cases (BNA).

F-Tags: F-Tags (short for “Federal Tags”) provide additional guidance on CMS regulations. F-Tags are published in the Appendices to the CMS State Operations Manual (Publication 100-07), available only on the CMS Web site.

Hospital Coverage: Hospital Compare, a joint project of the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services, lets you see how much Medicare paid for procedures at participating hospitals.

Inspector General Reports: Reports by the Department of Health and Human Services – Office of the Inspector General (“HHS-OIG Reports”) are posted free back to 1992 on the HHS-OIG Web site. Subscribers can get selected reports back to 1980 by from the CCH Medicare and Medicaid Guide on Intelliconnect.

Settlement Agreements: Medicare- and Medicaid-related Settlement Agreements may be posted on the Web site of the relevant government agency, the local Office of the U.S. Attorney or they may be linked from the docket sheet for a related case. If you can locate the article discussing the settlement in the BNA Health Care Fraud Reportor any other BNA publication you can purchase the Agreement from Bloomberg BNA Research & Custom Services (formerly BNA Plus)(703-341-3287 or research@bna.com). If that doesn’t work, try calling the government agency or, if you know of a related case, try to locate the document in the case file.

Medicaid and Refugees

A definition of Medicaid, in the context of refugee resettlement and non-emergency repatriation, may be provided here: A federally-funded entitlement program that provides medical assistance and benefits to individuals who meet eligibility criteria as outlined in the Family and Children’s Medicaid Manual, or in the Aged, Blind, and Disabled (Adult) Medicaid Manual.

Concept of Medicaid in Health Insurance Law

In this context, the following is a definition of Medicaid: A joint state and federal program that provides health care coverage to eligible categories of low-income individuals. Rules for eligible categories (such as children, pregnant women, people with disabilities, etc), and for income and asset requirements, vary by state. Coverage is generally available to all individuals who meet these state eligibility requirements. Medicaid often pays for long-term care (such as nursing home care). PPACA extends eligibility for Medicaid to all individuals earning up to $29,326 for a family of four.

Resources

See Also

  • Refugee Resettlement
  • Non-Emergency Repatriation

Concept of Medicaid in Health Insurance Law

In this context, the following is a definition of Medicaid: A joint state and federal program that provides health care coverage to eligible categories of low-income individuals. Rules for eligible categories (such as children, pregnant women, people with disabilities, etc), and for income and asset requirements, vary by state. Coverage is generally available to all individuals who meet these state eligibility requirements. Medicaid often pays for long-term care (such as nursing home care). PPACA extends eligibility for Medicaid to all individuals earning up to $29,326 for a family of four.

Resources

Notes and References

See Also

  • Doctors
  • Legal Medicine
  • Medicare
  • Hospitals
  • Medical Materials
  • Pharmaceuticals

Medicaid in the International Business Landscape

Definition of Medicaid in the context of U.S. international business and public trade policy: Federal-state program that pays for medical care for the poor.

Medicaid: Open and Free Legal Research of US Law

Federal Primary Materials

The U.S. federal government system consists of executive, legislative, and judicial branches, each of which creates information that can be the subject of legal research about Medicaid. This part provides references, in relation to Medicaid, to the legislative process, the federal judiciary, and the primary sources of federal law (cases, statutes, and regulations).

Federal primary materials about Medicaid by content types:

Laws and Regulations

US Constitution
Federal Statutory Codes and Legislation

Federal Case Law and Court Materials

U.S. Courts of Appeals
United States courts of appeals, inclouding bankruptcy courts and bankcruptcy appellate panels:

Federal Administrative Materials and Resources

Presidential Materials

Materials that emanate from the President’s lawmaking function include executive orders for officers in departments and agencies and proclamations for announcing ceremonial or commemorative policies. Presidential materials available include:

Executive Materials

Federal Legislative History Materials

Legislative history traces the legislative process of a particular bill (about Medicaid and other subjects) for the main purpose of determining the legislators’ intent behind the enactment of a law to explain or clarify ambiguities in the language or the perceived meaning of that law (about Medicaid or other topics), or locating the current status of a bill and monitoring its progress.

State Administrative Materials and Resources

State regulations are rules and procedures promulgated by state agencies (which may apply to Medicaid and other topics); they are a binding source of law. In addition to promulgating regulations, state administrative boards and agencies often have judicial or quasi-judicial authority and may issue administrative decisions affecting Medicaid. Finding these decisions can be challenging. In many cases, researchers about Medicaid should check state agency web sites for their regulations, decisions, forms, and other information of interest.

State rules and regulations are found in codes of regulations and administrative codes (official compilation of all rules and regulations, organized by subject matter). Search here:

State opinions of the Attorney General (official written advisory opinions on issues of state law related to Medicaid when formerly requested by a designated government officer):

Tools and Forms

Law in Other Regions

*This resource guide is updated frequently. However, if you notice something is wrong or not working, or any resources that should be added, please notify us in any of the "Leave a Comment" area.

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