medicaid visits

Published

Most of the patients I see are medicare patients, and after several months in HH, I have a pretty good handle on what is involved with these patients. I am however, still trying to work out the details of MEDICAID patients. What do your notes look like? And what about the visit itself? Are you doing a full assessment? Teaching?

Any insight or tips would be appreciated. Thanks!

Medicare eligibility isn't based on not being chronic/stable. You're either eligible for Medicare based on set criteria (65, permanent disability, ESRD) or you're not, there is no switching based on chronic illness becoming acute.

I don't mean that they would no longer have medicare coverage. I just meant that if a Pt is chronic/stable, there is no need for sn services, so medicare would not pay for sn services.

As for the criteria for medicaid to pay for sn services, I am wondering if that may vary state to state. I am going to look into this on the medicaid website.

Up Vote Up Vote ×
I don't mean that they would no longer have medicare coverage. I just meant that if a Pt is chronic/stable, there is no need for sn services, so medicare would not pay for sn services.

As for the criteria for medicaid to pay for sn services, I am wondering if that may vary state to state. I am going to look into this on the medicaid website.

I must have misunderstood, what did you mean by "they would be switched to Medicare if they were no longer chronic/stable"?

Up Vote Up Vote ×
I must have misunderstood, what did you mean by "they would be switched to Medicare if they were no longer chronic/stable"?

that the payer would be switched to medicare, vs the payer being medicaid.

I actually did find something on the medicaid website. I will link to it later, when I am on a computer.

Up Vote Up Vote ×
I don't mean that they would no longer have medicare coverage. I just meant that if a Pt is chronic/stable, there is no need for sn services, so medicare would not pay for sn services.

As for the criteria for medicaid to pay for sn services, I am wondering if that may vary state to state. I am going to look into this on the medicaid website.

Medicaid Benefits: Home Health Services, includes nursing services, home health aides, and medical supplies/equipment | The Henry J. Kaiser Family Foundation

There seems to be a great difference, my experience has been colored by MediCal's auth requirements for initial and ongoing care, which we don't usually receive prior to giving care and don't find out if covered or denied until after the services have been provided. If we accept a hospital referral we're basically taking our chances, and have had most denied, but provided the care anyway to avoid a delay in care. The MD and d/c planner can state the care is medically necessary, it is services that Medicare would cover and we provide the same documentation but we still are denied payment. They're basically pro bono cases for us and we're waiting to see how the ACA MediCal plans pay for services.

Up Vote Up Vote ×
I don't mean that they would no longer have medicare coverage. I just meant that if a Pt is chronic/stable, there is no need for sn services, so medicare would not pay for sn services.

As for the criteria for medicaid to pay for sn services, I am wondering if that may vary state to state. I am going to look into this on the medicaid website.

I must have misunderstood, what did you mean by "they would be switched to Medicare if they were no longer chronic/stable"?

Up Vote Up Vote ×
I don't mean that they would no longer have medicare coverage. I just meant that if a Pt is chronic/stable, there is no need for sn services, so medicare would not pay for sn services.

As for the criteria for medicaid to pay for sn services, I am wondering if that may vary state to state. I am going to look into this on the medicaid website.

Medicaid Benefits: Home Health Services, includes nursing services, home health aides, and medical supplies/equipment | The Henry J. Kaiser Family Foundation

There seems to be a great difference, my experience has been colored by MediCal's auth requirements for initial and ongoing care, which we don't usually receive prior to giving care and don't find out if covered or denied until after the services have been provided. If we accept a hospital referral we're basically taking our chances, and have had most denied, but provided the care anyway to avoid a delay in care. The MD and d/c planner can state the care is medically necessary, it is services that Medicare would cover and we provide the same documentation but we still are denied payment. They're basically pro bono cases for us and we're waiting to see how the ACA MediCal plans pay for services.

Up Vote Up Vote ×
that the payer would be switched to medicare, vs the payer being medicaid.

I actually did find something on the medicaid website. I will link to it later, when I am on a computer.

In California anyway, if a patient has Medicare, home health services would always be billed to Medicare, Medicare is always primary in the case of a Medi/Medi patient. If the services wouldn't be covered by Medicare due to chronic and stable, MediCal wouldn't cover them either (speaking of skilled services).

I had no idea that the benefits varied so much from state to state, or that you could bill either Medicare or Medicaid for skilled services depending on the patient's condition.

Up Vote Up Vote ×
Specializes in Pedi.
In California anyway, if a patient has Medicare, home health services would always be billed to Medicare, Medicare is always primary in the case of a Medi/Medi patient. If the services wouldn't be covered by Medicare due to chronic and stable, MediCal wouldn't cover them either (speaking of skilled services).

I had no idea that the benefits varied so much from state to state, or that you could bill either Medicare or Medicaid for skilled services depending on the patient's condition.

What the OP describes is the same as I've experienced in MA. I've always been told that Medicare only covers acute SN needs, not chronic. Mass Health is completely different. Mass Health ends up paying for a lot of services Medicare doesn't, especially for chronic patients. If the patient was admitted to the hospital and ended up with a wound or something, Medicare would become the payer. When someone has both, Medicare will always be the primary insurance but sometimes Medicare will not pay and Medicaid picks up the tab.

Mass Health does not require auth for SN visits. I have a lot of chronic kids who are on service mostly for med management/social issues. Some of my colleagues have a lot of adults who live in group homes on their services and, though these patients have Medicare and Medicaid, Medicaid is the payer for their services more often than not.

Up Vote Up Vote ×
What the OP describes is the same as I've experienced in MA. I've always been told that Medicare only covers acute SN needs, not chronic. Mass Health is completely different. Mass Health ends up paying for a lot of services Medicare doesn't, especially for chronic patients. If the patient was admitted to the hospital and ended up with a wound or something, Medicare would become the payer. When someone has both, Medicare will always be the primary insurance but sometimes Medicare will not pay and Medicaid picks up the tab.

do you find that your visits and notes look different than those that you do for medicare patients?

Up Vote Up Vote ×
Medicaid Benefits: Home Health Services, includes nursing services, home health aides, and medical supplies/equipment | The Henry J. Kaiser Family Foundation

There seems to be a great difference, my experience has been colored by MediCal's auth requirements for initial and ongoing care, which we don't usually receive prior to giving care and don't find out if covered or denied until after the services have been provided. If we accept a hospital referral we're basically taking our chances, and have had most denied, but provided the care anyway to avoid a delay in care. The MD and d/c planner can state the care is medically necessary, it is services that Medicare would cover and we provide the same documentation but we still are denied payment. They're basically pro bono cases for us and we're waiting to see how the ACA MediCal plans pay for services.

It is rather interesting that medicaid coverage varies so greatly state to state.

This is the link I found last night:

Massachusetts Medicaid Waiver

Up Vote Up Vote ×
Specializes in Pedi.
do you find that your visits and notes look different than those that you do for medicare patients?

No, but as I said earlier in the thread, I have Medicare patients once in a blue moon. I have had 2 kids over my 3 years at my job who had Medicare d/t renal failure and a few disabled people in their 20s.

Up Vote Up Vote ×

I'm going to have to ask around the office, we have travelers from out of state and our company has offices in several states, I have over 15 yrs in HH and I have never heard of billing MediCal for skilled services on a Medicare patient, but maybe they just never talk about what they have in the other states.

Up Vote Up Vote ×
+ Join the Discussion