The pandemic, more unemployed Americans, more healthcare organizations struggling financially, and the proliferation of health services now covered under telehealth—these are among the reasons why providers not yet enrolled in Medicaid may find benefits in doing so. Here are four fast facts to get acquainted with a potential new revenue stream—enrolling as a Medicaid provider.
1. States hold the reins
Because Medicaid is a cooperative arrangement between the federal government (which largely subsidizes the program) and states that administer their respective Medicaid programs, practitioners providing Medicaid or Children’s Health Insurance Program (CHIP) services must enroll in, and adhere to, each state’s program. While there are federal guidelines—for example state Medicaid agencies must revalidate the enrollment of all providers, regardless of provider types, at least every five years (42 CFR 455.414)—most administration exists at the state level.
2. All states participate in Medicaid on some level
In 2014, the Affordable Care Act (ACA) offered states the option to expand their Medicaid programs to cover more low-income beneficiaries using a graduated funding scale. (Households with income below 133% of the federal poverty level qualify.) Today 36 states and Washington D.C. provide expanded coverage, and more are actively considering expansion. A recent study showed reduced uninsured rates among unemployed adults in states that expanded Medicaid eligibility under the ACA starting in 2014. As states decide to expand Medicaid, it will present new opportunities for providers to enroll.
3. Changes present opportunity
CMS rolled out modifications to Medicaid and CHIP to eliminate distractions and barriers to frontline providers enrolled in Medicaid (or planning to enroll) and caring for the sickest and most vulnerable patients during COVID-19.
- Whether or not your healthcare organization is in a state that opted into expanded Medicaid coverage, there are new relaxed rules—some permanent and others temporary. An FAQ document released by CMS provides guidance to states on the allowances, which in turn affect providers enrolled in the program.
- A 1135 Medicaid & CHIP Checklist provided by CMS includes allowances across many areas— from Medicaid authorizations to long-term services and supports, provider enrollment, fair hearings, reporting and oversight, and more.
- States may elect to operate a Basic Health Program (BHP) to cover individuals under age 65 with household incomes between 133% and 200% of the federal poverty level who are ineligible for Medicaid, CHIP, or affordable employer-sponsored coverage. This expansion, too, would provide opportunity for Medicaidenrolled providers in BHP-participating states to see additional patients.
4. Non-physicians benefit, too
Expanded opportunity for nonphysicians enrolled in Medicaid exists in waivers related to home health, following the pandemic. The CARES Act permanently modifies Medicare and Medicaid home health benefits (42 CFR 440.70) by updating which practitioners can order the benefits. While the revisions don’t change the scope of services authorized under the new mandatory home health benefit, they now allow Medicaid-enrolled NPs, PAs, and clinical nurse specialists to order home health services. Previously, only physicians could order the service.
The Provider Enrollment Services team at symplrCVO specializes in enrolling your applicants into federal, state, and commercial payer insurance plans. The result: Faster reimbursement for the care and services your practitioners deliver.
